Independent maternity and neonatal investigation: terms of reference (Department of Health and Social Care, 15 September 2025)

Summary

On 23 June 2025 the Secretary of State for Health and Social Care announced a rapid, national, independent investigation into NHS maternity and neonatal services. Chaired by Baroness Amos, this document sets out the terms of reference for the investigation.

Content

The aims of the investigation are to:

• develop and publish one set of national recommendations to:
  • drive the improvements needed to ensure high-quality and safe maternity and neonatal care across England
  • reduce inequalities and promote health equity in the delivery of those services
  • help bereaved and harmed families to receive justice and accountability in the future
• ensure that the lived experiences of women, babies and families, including fathers and non-birthing partners, are fully heard and used to inform the development of the national recommendations
• conduct and publish 14 local investigations of maternity and neonatal services in NHS trusts and use these alongside other sources of data and evidence gathered by the investigation to inform the development of the national recommendations

The individual trusts to be reviewed are:

• Blackpool Teaching Hospitals NHS Foundation Trust
• Bradford Teaching Hospitals NHS Foundation Trust
• University Hospitals of Leicester NHS Trust
• Leeds Teaching Hospitals NHS Trust
• Sandwell and West Birmingham Hospitals NHS Trust
• Gloucestershire Hospitals NHS Foundation Trust
• Somerset NHS Foundation Trust
• Oxford University Hospitals NHS Foundation Trust
• University Hospitals Sussex NHS Foundation Trust
• Barking, Havering and Redbridge University Hospitals NHS Trust
• Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
• University Hospitals of Morecambe Bay NHS Foundation Trust
• East Kent Hospitals NHS Foundation Trust
• Shrewsbury and Telford Hospital NHS Trust

The investigation started work in summer 2025. Some initial findings will be published in December 2025 ahead of further findings in spring 2026.