All-Party Parliamentary Group on Patient Safety: Submission to the National Maternity and Neonatal Investigation (March 2026)

Summary

The All-Party Parliamentary Group (APPG) on Patient Safety welcomes the National Maternity and Neonatal Investigation (NMNI) led by Baroness Amos, and the opportunity to contribute to its work.

To inform this submission, the APPG for Patient Safety convened a roundtable discussion in January 2026 bringing together bereaved families, senior clinicians, Royal College leaders, NHS England representatives, academics and patient safety organisations.

Content

The discussion reflected perspectives from those directly affected by maternity failures as well as those responsible for delivering and improving services.

A clear consensus emerged across participants. The system is not short of inquiries or recommendations. Over the past decade, investigations into Morecambe Bay, Shrewsbury and Telford, and East Kent have exposed serious failures and produced hundreds of recommendations. Yet many of the same issues continue to recur: poor teamwork, weak accountability, defensive cultures and a failure to translate learning into sustained change.

Participants emphasised that further operational recommendations alone will not solve these problems. Instead, the final report from the investigation should focus on a small number of structural reforms capable of transforming how maternity services are organised, led and held accountable.

The APPG for Patient Safety has separately urged the Secretary of State for Health and Social Care to maintain the statutory independence of the Health Service Safety Investigation Branch (HSSIB) and not proceed with plans to fold HSSIB into the CQC.

Drawing on the roundtable discussion, the APPG urges the investigation not to place disproportionate emphasis on staffing or funding. Both matter, but since 2014, per delivery there are now significantly more staff:

• 93.1% more neonatal nurses
• 29.7% more midwives
• 52.3% more obstetricians and gynaecologists

That may have contributed to a fall in the perinatal mortality rate in England - meaning around 700 fewer baby deaths per year. The APPG therefore urge the National Maternity and Neonatal Investigation (NMNI) to look at structural reforms which, in the APPG’s view, are more likely to lead to an immediate improvement in safety and experience.