Women not listened to, staff close to burnout and a culture of ‘that’s the Oxford way’ are just some of the concerns raised in the investigation.

Published on Tuesday, the report found that the maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre with an a focus on listening to women.

Oxford University Hospitals Trust bosses are now aware of what is wrong with the wards at the John Radcliffe and Horton Hospital in Banbury.

READ MORE: IN FULL: National investigation into Oxford hospital’s maternity ward

READ MORE: Hospital boss tells women ‘we failed you… and we are deeply sorry’

Simon Crowther, interim chief executive of OUH, said the findings will be put “at the heart” of its improvement plans.

He acknowledged that trust in the maternity services is “badly damaged” and said the next move will matter, not words.

“Women, families and staff will be directly involved in informing, shaping and delivering the changes we make,” he said.

“We will listen, act honestly, and be open about the progress we are making and the progress we still have to make.”

Indeed, CQC inspections published earlier in June rated both maternity services as ‘Good’, which is an improvement from their previous ratings of ‘Requires Improvement’.

However, these inspections were also carried out by the watchdog in October 2025 whereas Baroness Amos’ investigation team visited for three days over the following two months.

OUH says that following staff feedback, “significant improvements” were made to facilities and the environment, including decluttering the department and investing in new cots and equipment.

It also previously noted staff turnover had dropped from 10.4 per cent in 2022 to 3.9 per cent today.

NHS England will now be leading the more immediate actions and plans going forward.

The government will introduce the first ever commissioner to speak up for women, babies and families of maternity care in England.

But a national action plan will be published in December to overhaul services and drive long-term change – with further details on how services at the JR can change expected.

This will be driven by a taskforce, bringing together families, clinicians and other experts with a clear focus on safety, equity and accountability.

An additional £41 million investment to improve safety at maternity and neonatal facilities has also been announced.

Kate Brintworth, chief midwifery officer for England, said NHS leaders met on Tuesday to set out immediate actions that can be taken across the country.

NHS England has been approached for further details on OUH’s forward plan.

Nathan Bream, of North Bush Furlong in Didcot, pleaded guilty to two counts related to the offences, which took place in Didcot between June 9, 2022, and January 18, 2025.

The 21-year-old was found to have made five category A videos and six category B videos during that period.

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At Wycombe Magistrates’ Court on June 19, he was ordered to complete 26 days of a rehabilitation programme, up to 20 days of appointments with a responsible officer, and 150 hours of unpaid work within 12 months.

He was also ordered to pay £85 in court costs and a £114 victim surcharge and will remain under supervision until December 18, 2027.

A sexual harm prevention order and notification requirements were imposed for five years.

Bream’s phone was ordered to be destroyed under Section 1(2) of the Prevention of Crime Act 1953.