Independent Investigation into Maternity and Neonatal Services in England – Final report and recommendations (30 June 2026)

Summary

On the 23 June 2025 the Secretary of State for Health and Social Care (DHSC) announced a rapid, national, independent investigation into NHS maternity and neonatal services. This final report highlights key areas of concern, identifies barriers to delivering change and sets out a robust package of eight recommendations aimed at delivering long-term systemic and cultural transformation in maternity and neonatal care. It builds on an interim report published in February 2026.

Content

The report makes eight recommendations aimed to address the systemic problems identified in this report:

1. The Department of Health and Social Care (DHSC) must create a statutory Maternity and Neonatal Commissioner, introducing legislation into the Health Bill at the earliest possible opportunity, and appointing a Commissioner within six months of Royal Assent.
2. DHSC, NHS England (NHSE), Integrated Care Boards (ICBs) and NHS trusts must take action to listen to the voices of women, birthing people and families within 12 months.
3. DHSC, NHSE and CQC must drive improvement, within 12 months, of the quality, transparency, oversight and accountability of investigations and ensure learning is captured and acted upon when things go wrong.
4. DHSC/NHSE must design a Modern Service Framework for maternity and neonatal services within 12 months and begin rollout within 18 months.
5. DHSC, NHSE, ICBs, NHS trusts, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) must treat racism, discrimination and inequality as a critical maternity safety issue – within 12 months, with work starting immediately.
6. DHSC/NHSE must clarify existing system governance, oversight and accountability structures and improve the effectiveness of regulatory oversight within nine months.
7. DHSC, NHSE, ICBs and NHS trusts must work with colleges, universities, post graduate educators and others to improve culture and teamworking, and strengthen leadership at all levels of the system and across professions within 12 months.
8. DHSC/NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, five-year and 10-year investment commitments and implementation deadlines.