(30th June 2026) Baroness Amos has today published the final report and recommendations of the Independent National Maternity and Neonatal Investigation.
She has 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, embed a focus on listening to women, and ensure anti-racist practice at every level.
The report highlights key areas of concern, identifies barriers to delivering change and sets out a robust package of recommendations aimed at delivering long-term systemic and cultural transformation in maternity and neonatal care for the 21st century, with accountability, equity, excellence and compassion at its core.
Baroness Amos outlines several themes repeatedly heard from women, families and staff:
- Women are not being listened to, heard or believed, with serious consequences for safety and quality of care, resulting in avoidable harm, trauma and loss of confidence in themselves and in the system.
- Racism and discrimination are embedded throughout the maternity and neonatal system, with unacceptable impact on safety, equity and quality of care, and staff wellbeing.
- Service design and planning is slow to respond to safety and demand and is not equipped to meet the changing needs of women, babies and families – including the changing profile of women giving birth and the increase in medical interventions during births.
- The system is fragmented and care is inconsistent – antenatal, birth and labour, neonatal and postnatal services are not joined up.
Since September 2025, the Investigation has listened directly to over 450 families from across the country and received more than 10,500 responses to a public Call for Evidence. Over 9,000 staff contributed through surveys, Trust visits and one-to-one interviews. In addition, 38 national leaders were interviewed and evidence panels were convened with national stakeholder organisations to understand system-wide challenges and solutions.
The Investigation analysed over 9,500 pieces of evidence, including data and documentation, and undertook a review of previous recommendations to understand why previously proposed changes have not been implemented or sustained. Visits to 12 NHS trusts, selected to reflect geography, socio-economic variation, trust type, case mix and feedback from families, provided direct insight into frontline care, leadership, culture and operational pressures.
The report sets out eight recommendations to redesign the maternity and neonatal system and deliver fundamental change:
- The creation of a statutory national Maternity and Neonatal Commissioner to drive the urgent, systemwide change identified by the Investigation and provide leadership for a redesigned maternity and neonatal system, through the Health Bill currently before Parliament;
- Systematically listening to the voices of women and families;
- Improving how the system responds when something goes wrong, including providing a sincere apology and learning lessons;
- Creating a modern service framework which sets out national standards to consistently achieve high quality maternity and neonatal care;
- Tackling racism, discrimination and inequality;
- Improving system governance and accountability structures and regulatory oversight;
- Improving culture and teamworking, and strengthening leadership at all levels of the system and across professions;
- Delivering estates and digital systems that are fit for modern maternity and neonatal care.
The Investigation has also identified additional actions that can start now, which will make a significant difference to the experience of women and families and the ability of staff to provide safe care. This includes NHS trusts urgently reviewing their maternity triage processes, the ‘Emergency Department’ for maternity care.
Further actions include guidance for situations where women decline recommended clinical care, a Government response to the 2019 consultation on coronial investigations of stillbirth cases in England and Wales, and consideration of the benefits and drawbacks of an alternative compensation system for adverse events in maternity and neonatal services.
The National Maternity and Neonatal Taskforce, chaired by the Secretary of State for Health and Social Care, will develop and oversee a new national action plan in response to Baroness Amos’s findings.
Baroness Amos said:
“Women, babies and families deserve maternity and neonatal care that is safe, compassionate and equitable wherever they live. Too often, this Investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong.
“This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it.
“These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability, and create a system that learns when harm occurs.”