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Independent Investigation into Maternity and Neonatal Services in England – Reflections and Initial Impressions

Introduction

When I was asked by the Secretary of State for Health and Social Care to chair a rapid investigation into maternity and neonatal services in England, I knew that it would be challenging. I could not understand why, having read the media reports over the years of the experiences of harmed and bereaved families, so little seemed to have changed and why families continued to go through such trauma and distress. I expected to hear experiences from families about where they had been let down by the care they had received in maternity and neonatal units across the country, but nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing.

Since 2015, there have been a significant number of independent investigations and reviews of maternity and neonatal services in NHS Trusts across England. This is in addition to national reviews looking at patient safety and care, which impact on maternity and neonatal services, as well as reviews by regulatory bodies in England, such as the Care Quality Commission (CQC). At the time of writing, the NHS has recorded a staggering 748 recommendations relating to maternity and neonatal care, the majority of which have been made since 2015, and other organisations have also made recommendations. This naturally raises an important question: with so many thorough and far-reaching reviews already completed, why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country? The aim of this investigation is to develop national recommendations that, once put into practice, will help ensure that safe, compassionate care is consistently delivered everywhere.

This paper sets out my reflections on what I have heard to date from my engagement with families, staff, community organisations and MPs. It also sets out the approach to setting up and delivering the investigation, updates on key areas of work and the investigation’s next steps. At this stage, I have not included early findings or recommendations because I need to gather further evidence to inform my thinking. Key elements of this evidence gathering will be the forthcoming Call for Evidence, which will ask women, families, fathers and non-birthing partners about their experience of maternity and neonatal care (to launch in January 2026), and the completion of site visits to 12 NHS Trusts (also in January 2026).

I have heard a wide range of views from families and am grateful for the constructive and honest feedback I have received. In my engagement with families there has been some criticism of the investigation from the outset. Some have said they would like to see a statutory public inquiry, as it is the only way that they consider they will achieve justice for their loved ones, including their children. Some families would like to have been more closely involved in determining the direction of the investigation through a co-production model, rather than the engagement and consultative processes we have established. There has also been disappointment that the rapid nature of the review precludes an in-depth examination of the regulatory bodies. In addition, I know some families feel that justice cannot be delivered without individual case reviews, which I will not be carrying out as part of this investigation.

But I have also heard from families who support the investigation and its focus on finding solutions to systemic challenges, and who have shared their experiences with me. I am hopeful that the work of the investigation, including the final report and national recommendations, will lead to systemic reform which will help families to receive justice and accountability in the future, as well as propelling systemic change for maternity and neonatal safety within the NHS.

I would like to thank all the families who have engaged with me, my Expert Advisors and the investigation team through evidence sessions, one to one meetings, giving feedback on documents and via correspondence. I am conscious that engaging with the investigation increases the number of times families have been asked to recount their experiences and relive trauma.

While the issues I have heard about through this engagement have been extremely varied, there are a set of issues which I have heard about consistently. These include:

  • a lack of communication and support from clinical teams and organisations
  • women not being listened to or given the right information to make informed choices at critical moments of their care as risk profiles change
  • women’s knowledge of their own bodies and important information essential to clinical decision making about their care, such as reduced fetal movement, sometimes being disregarded
  • fathers and non-birthing partners feeling unsupported
  • the desire for a more holistic approach to care across a woman’s maternity and post-natal journey, with maternity and neonatal teams working together to maximise good outcomes for women, their babies and families
  • the impact of discrimination against women of colour, working class women, women with mental health challenges and younger parents leading to poorer outcomes
  • a lack of empathy, care or apology, both as part of clinical care and after things have gone wrong, with women feeling blamed and guilty; a lack of recognition from staff when care is not delivered to the correct standards
  • lack of family engagement in reviews of care and feedback of review reports
  • an overly legalistic, adversarial approach when concerns or complaints are raised
  • the failure of regulatory bodies to protect vulnerable women and families and the perception of health professionals and organisations ‘marking their own homework’
  • failure to address poor behaviour, including the use of inappropriate language when communicating with women, families and non-birthing partners
  • the length of time autopsy reports take to be produced, delaying families from being able to fully grieve for their children
  • poor standards of basic care, such as lack of cleanliness, women and non-birthing partners not receiving meals, women not being helped to use the bathroom, and catheters not being checked or emptied
  • women and families finding it difficult to access their medical notes (and notes being redacted or observations filled in at a later date)
  • birth plans not being read or followed, leading to women not being cared for in the way they wanted or had agreed, as well as having to repeat their wishes multiple times
  • women and families being placed in inappropriate spaces after loss or harm, for example, being put on wards with newborns after they have experienced a loss
  • the impact of different philosophies around birth and pregnancy on women’s experience and ability to make informed choices
  • having to work with multiple contacts when a baby dies, with issues arising from information not being shared sufficiently between different services
  • the lack of recognition of, and support for, the long-term impact that these negative and traumatic experiences of services can have on families, for example: family breakdown; long-term impacts on the mental health of women and families; support for raising children with lifelong disabilities; bereavement care; participation in reviews or investigations; joint planning of complex care; and the need for neonatal unit accommodation and transition care

I have also heard from some families about the high-quality, compassionate care they have received.

Setting up the Investigation

Following the announcement of the investigation, my team and I began consulting on the Terms of Reference, for which I sought families’ input, in order to reflect their concerns and expectations, while also remaining conscious of the timeframe set by the Secretary of State. The published Terms of Reference were structured around five different areas of work:

  1. Local investigation phase
  2. System wide review – including evidence from families, staff, previous reviews, academic experts, national healthcare leaders and other community engagement
  3. Inequalities – specifically developing an understanding of the experience of women, families and non-birthing partners from Black, Asian and other seldom heard communities
  4. A review of the legal framework regarding the role of Coroners in relation to stillbirths and compensation following harm caused by clinical negligence
  5. The development of one set of national recommendations

 

When selecting Trusts for the local investigation phase, I wanted to make sure that there was sufficient variety, not just geographically but also in terms of demographics, the mix of cases and the different types of Trust. In selecting Trusts, I also took into consideration poor outcomes, such as perinatal mortality rates, and poor experience, such as patient survey data, in addition to Trusts proposed by bereaved and harmed families who had experienced failures in maternity care. However, I want to make clear that, although we are conducting local investigations of specific Trusts, the aim of the investigation is to identify systemic, national issues in maternity and neonatal care and make recommendations to address those. The local investigations will not, therefore, consist of a formal evaluation or assessment of a Trust’s performance or the performance of individual staff members.

I had originally planned to investigate 14 hospital Trusts; however, I made a decision to remove 2 Trusts from the scope of the investigation: Leeds Teaching Hospitals NHS Trust was removed following the Secretary of State’s announcement in October 2025 that he would be commissioning an independent inquiry into the Trust’s maternity units; and Shrewsbury and Telford Hospital NHS Trust was removed following discussions with West Mercia Police about the detail and schedule of their ongoing criminal investigation.

Investigation Updates

This section provides an overview of the work we have undertaken since the publication of the investigation’s Terms of Reference in September. Since this point, my team and I have:

  • Met over 170 individual family members to gather evidence and hear about their lived experiences. In all of our engagement, my team and I have followed a ‘families first’ approach, meeting with families in advance of visiting every Trust to ensure their evidence informs and guides our site visit as well as informing the development of the future national recommendations. Free emotional and psychological support online and on-site has been provided in all the evidence sessions with families, as I recognise that engaging with the investigation can be emotionally distressing. Families can also use this support before and after giving evidence, and staff are able to use their Trust’s support programme.
  • Consulted families on a number of key documents and areas of work for the investigation, including the Terms of Reference, recruitment of external expert advisors, the investigation methodology and family engagement strategy, and the draft Call for Evidence survey. We have also asked families for input as part of our work reviewing previous maternity and neonatal recommendations and reviewing the legal frameworks for Coronial involvement in stillbirths and compensation arising from harms sustained from clinical negligence.
  • Undertaken site visits in Barking, Oxford, East Kent, Kings Lynn, Somerset and Bradford, as of 2 December, as part of the local investigation phase, and we will have visited Gloucestershire by the time this is published.
  • Met staff including midwives, doctors and neonatal nurses on site visits as well as Trust Executive teams, to hear about their experiences of working in maternity and neonatal services, to understand their perspective on areas requiring improvement as well as on what works well.
  • Spoken with a number of organisations and stakeholders as part of the investigation’s focus on inequalities.
  • Started to undertake a desktop review of the legal framework for Coronial involvement in the investigation of stillbirths, with thanks to families who suggested including this issue in the Terms of Reference. I recognise that the reference to ’37 weeks or later’ has been upsetting for some families and want to offer reassurance that the methodology and evidence gathered will not be restricted to 37 weeks.
  • Undertaken initial engagement with international academic experts in order to identify good practice in maternity and neonatal care from other countries.
  • Begun work to review previous recommendations made relating to maternity and neonatal care, working with families to develop the approach to be taken in conducting the review.
  • Appointed a group of eight Expert Advisors with a wide range of clinical experience and expertise, from a variety of professions to support the work of the investigation. I would like to put on record my thanks to them for bringing their specialist knowledge and energy to the investigation – details on the Expert Advisors are provided below.

Expert Advisors – Areas of Expertise

Midwifery

  • Professor Julia Sanders
  • Lesley Sharkey

Obstetrics

  • Professor Alex Heazell
  • Dr Christine Ekechi

Neonatology

  • Dr Edile Murdoch
  • Dr Alison Bedford-Russell

Public health and Inequalities

  • Professor Joht Singh Chandan

Investigations

  • Dr Bill Kirkup

Engagement with Staff

We have spoken with frontline staff, who have been open and frank about the pressures they are under, their experiences working in maternity and neonatal services and about the areas that require improvement. We have heard about the challenges that staff are facing as they deliver maternity and neonatal services to women and their families. We were told that staff have had rotten fruit thrown at them and that others have faced death threats after negative publicity and social media posts about the standard of maternity care in their unit. We were told that negative publicity about a unit can make delivering high quality care all the more difficult. Trusts have a duty of care towards staff, the majority of whom are committed to delivering safe, compassionate care to women, babies and families. Staff need to be provided with the necessary support in the face of intensive media scrutiny. 

Staff also talked about the way adverse media attention had acted as a catalyst for improvements in women’s experience of pregnancy and labour including increased accessibility, visibility and presence of senior midwifery leaders. Staff commented positively on the impact of these changes on morale. Such changes had also led to early resolution of staff concerns and a more positive experience for women and their partners. The development of specialist midwifery posts, such as bereavement pathway midwives and midwives leading on addressing inequalities, also had a significant impact on the experience of some women and their families. These posts had also raised awareness of inequalities issues amongst staff. Staff also told us about the pressures they face, including being pulled onto time critical areas of care, increased reporting processes, issues with hospital facilities and estates, lack of interoperability of IT systems, and the impact of different leadership styles on delivery of care.

Despite the challenges, many staff are proud of the compassionate and personalised care they are able to offer to families. Even at this early stage of the investigation, staff are clear that significant improvements can be made and sustained in maternity and neonatal services with focused resources, prioritisation and engagement from Trust leadership and close system oversight.

Wider Stakeholder Engagement

In addition to all the insightful feedback I have heard from families and staff on the site visits, I have also engaged with a wider range of stakeholder groups, as I am keen to hear from women and families from different backgrounds, including from seldom heard communities.

This engagement has included hosting a community stakeholder engagement event in Leicester, focused on maternity and neonatal care for Asian women and families. Some of the issues that I heard about consistently centred around:

  • continuity of midwifery and medical care during the antenatal and postnatal periods
  • culturally appropriate care and support
  • clear communication between clinical teams and families
  • the importance of good translation services
  • considering the trauma impact of discrimination and racism on an individual and their family so care is planned optimally

I also hosted a meeting with organisations and researchers working with Black women and families. Some of the issues that were raised included:

  • the importance of improving ways to reach and work with women and families who may be fearful of engaging with the system, who are unsure how to or for whom there are language or cultural barriers
  • the lack of trust in the maternity system held by Black women
  • the benefits of using faith leaders or community organisations trusted by families and that support families to feel safe
  • the importance of improving communication between families and healthcare professionals to provide more culturally sensitive care, especially when communicating risk
  • concerns around how systemic racism and stereotyping can impact on how Black women are treated and the care they receive
  • the importance of research and innovation funding for identifying solutions that tackle inequalities

Next Steps Towards Final Report

I have always planned to publish my final report and recommendations in Spring 2026 – this remains the case. As our evidence gathering has taken shape and the Trust site visits now go into the new year, I concluded that I should publish two updates prior to my final recommendations: this reflections piece and, in February 2026, a report on the initial findings of the investigation following the conclusion of the site visits.

Local Investigation Phase

For the remainder of December 2025 and in January 2026, the programme of site visits to hospital Trusts will continue. The Trusts to be visited are:

  • Blackpool Teaching Hospitals Foundation NHS Trust
  • University Hospitals of Leicester NHS Trust
  • University Hospitals Sussex NHS Foundation Trust
  • Sandwell and West Birmingham Hospitals NHS Trust
  • University Hospitals of Morecambe Bay NHS Foundation Trust

Following the conclusion of the site visits, I will publish reports on the 12 local investigations of maternity and neonatal services in NHS Trusts. These reports will synthesise the evidence we have received and contribute to our understanding of the systemic issues requiring attention. Publishing these reports will help to ensure that the Maternity and Neonatal Taskforce, chaired by the Secretary of State, is able to consider local findings as it develops its forward plan of work.

System Wide Review

I will launch a Call for Evidence for families in January 2026, which will be open for 8 weeks. I hope that families across the country will complete the survey and give feedback. I want to gather as much evidence as possible to support the recommendations I make.

I also want to make sure that we are hearing views from staff across the country and am finalising plans for how we will collect this evidence. 

As part of the system wide review of evidence, I will also begin interviews with representatives from national organisations including:

  • Care Quality Commission (CQC) – Chair and CEO
  • DHSC Chief Scientific Advisor
  • DHSC Chief Medical Officer
  • General Medical Council (GMC)
  • Healthcare Services Investigation Branch – Chair & CEO
  • Maternity and Newborn Safety Investigations Programme (MNSI)
  • NHS England – Chair, CEO, Chief Nursing Officer, Chief Midwife
  • NHS England National Clinical Director for Maternity
  • NHS England National Clinical Director for Neonatology
  • NHS England National Clinical Director for Women’s Health
  • NHS England National speciality advisors
  • Nursing and Midwifery Council (NMC)
  • Royal College of Midwives (RCM)
  • Royal College of Obstetricians and Gynaecologists (RCOG)
  • Royal College of Paediatrics and Child Health (RCPCH)
  • British Association of Perinatal Medicine (BAPM)

I will continue the review of previous recommendations made into maternity and neonatal care. This will help me to better understand the impact of previous recommendations on the care of women and their babies and how those recommendations have been implemented and change sustained.

I will also continue to work with international experts to identify examples of good practice in maternity and neonatal care, both within the UK and internationally, and which relate to the investigation’s core themes of quality, safety and the experience of women and families.

Inequalities

I have begun engaging with voluntary and community sector organisations to facilitate family evidence panels with seldom heard from communities facing health inequalities. This includes inequalities relating to ethnicity, disability, socioeconomic status, neurodiversity, gender identity and other factors. These sessions will continue in the new year.

A review of the legal framework regarding the role of Coroners in relation to stillbirths and compensation arising from harms sustained from clinical negligence

Interviews will be conducted with a range of relevant individuals and organisations including families who have expressed an interest in this area, in addition to the Chief Coroner, the National Medical Examiner, the Department of Health and Social Care, the Ministry of Justice, academic legal experts and representatives from the Irish Government.

I will also continue to engage with families about their experience relating to compensation arising from harms sustained from clinical negligence as part our review of the legal framework.

The development of one set of national recommendations

The evidence collected through all the different areas of work outlined above will be used to build one set of national recommendations to improve the safety and experience of maternity and neonatal care. This will be published as part of the final report.

I am following the work of the National Assessment of all Maternity and Neonatal Services in Wales, which is still ongoing, and will be reviewing the findings of the recent report published on Enabling Safe Quality Midwifery Services and Care in Northern Ireland.

Conclusion

I would like to thank everyone who has engaged with the work of the investigation so far. As I said in the introduction to this report, I do not understand why change has been so slow. It is clear from what I have already seen that change is not only possible, but also necessary and it is urgent. The investigation team and I have a great deal more work to do. I remain committed to completing the investigation in line with the timelines set out and have full confidence that we will develop national recommendations which will drive the fundamental improvements in Maternity and Neonatal services in England which are so urgently required. I look forward to publishing my findings next year.

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