Independent Investigation into Maternity and Neonatal Services in England – Reflections and Initial Impressions (9 December 2025)

Summary

On the 23 June 2025 the Secretary of State for Health and Social Care announced a rapid, national, independent investigation into NHS maternity and neonatal services. In this report the investigation’s Chair, Baroness Amos, provides an update on its progress since the publication of its Terms of Reference in September 2025. She outlines the activities undertaken as part of the investigation to date and her initial reflections from engagement with families, staff, community organisations and Members of Parliament.

The investigation's interim report, published on the 26 February 2026, can be found here.

Content

In her initial report, Baroness Amos highlights that the following set of issues have been raised with her consistently:

• 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.

Next steps

In this document Baroness Amos states that the investigation will:

• launch a call for evidence in January 2026, which will be open for 8 weeks
• publish a further update in February 2026 on the initial findings of the investigation following the conclusion of site visits to hospital Trusts.
• following the conclusion of site visits, publish reports on the 12 local investigations of maternity and neonatal services in NHS Trusts.
• publish a final report in Spring 2026 which will include one set of national recommendations to improve safety and experience of maternity and neonatal care.