Independent Investigation into Maternity and Neonatal Services in England: Final Report and Recommendations, chaired by Baroness Valerie Amos.

Overall message

Maternity and neonatal services in England are not consistently safe, compassionate, fair or joined up. The report calls for urgent reform so that safety, equity, compassion and the voices of women, birthing people and families are at the centre of care.

1. What the investigation looked at

The investigation was set up to understand why avoidable deaths, harm and trauma continue to happen in maternity and neonatal services, despite previous reviews and recommendations.

The investigation heard directly from over 450 families, received over 10,500 public responses, visited 12 NHS trusts and heard from over 9,000 staff through surveys, visits and one-to-one discussions.

The report says the system needs urgent reform because current services are fragmented, under pressure, too slow to learn and not consistently designed around the needs of women, babies and families.

2. Main findings

Women and families are not always listened to

Many families said their concerns were dismissed, minimised or not believed. This included concerns about pain, reduced baby movements, bleeding, trauma, consent and the feeling that something was wrong.

Racism, discrimination and inequality affect safety

The report says racism and discrimination are embedded in the system and must be treated as maternity safety issues, not just equality or training issues.

Care is too fragmented

Families can move between antenatal care, labour and birth, neonatal care, postnatal care, mental health support, community care and GP services without the system joining up properly around them.

The system is under serious pressure

Staff described workforce shortages, poor culture, weak leadership, outdated buildings, poor digital systems and too many disconnected investigations and recommendations.

Learning after harm is not strong enough

When things go wrong, families often experience poor communication, delayed answers, repeated retelling of trauma and a lack of accountability.

3. The eight main recommendations

The report makes eight main recommendations to change the system:

No.	Recommendation	Meaning
1	Create a statutory Maternity and Neonatal Commissioner	The Commissioner would report to Parliament, hold the system to account and oversee the redesign of maternity and neonatal services.
2	Listen to women, birthing people and families	Listening must be treated as a safety requirement. Concerns should be captured, reviewed through patient safety systems and escalated to board level where patterns emerge.
3	Improve investigations and learning after harm	Families should receive clearer information and the system should investigate harm with transparency, independence, learning and accountability.
4	Create a Modern Service Framework	This would set national standards for safe, high-quality care across the whole pathway, including triage, workforce models and service design.
5	Tackle racism, discrimination and inequality	Racism, discrimination and inequality must be treated as critical safety issues, with better data, stronger accountability and action from leaders and regulators.
6	Clarify governance and accountability	The report calls for clearer responsibility across DHSC, NHS England, ICBs, trusts and regulators, so that oversight and accountability are not blurred.
7	Improve culture, teamwork and leadership	The system must tackle bullying, racism and poor behaviour, strengthen leadership and improve multidisciplinary teamworking.
8	Invest in safe buildings and digital systems	Maternity and neonatal estates must be safe and fit for purpose, and every woman and baby should have one digital record that follows them across services.

4. What the report says should happen now

·        Legislate for a new statutory Maternity and Neonatal Commissioner.

·        Urgently improve maternity triage so it is treated as a safety-critical service, not an add-on to labour ward staffing.

·        Ensure dedicated midwives are available to answer triage calls and give timely advice, including face-to-face appointments if women remain concerned.

·        Create clear escalation pathways, senior clinical decision-making cover day and night, and board-level oversight of triage performance.

·        Complete a board-level audit of maternity triage provision within three months.

·        Produce national guidance where women decline recommended clinical care or choose birth outside existing clinical guidance.

·        Respond to the consultation on coronial investigations of stillbirths.

·        Explore a less adversarial compensation system for maternity and neonatal harm.

5. Why this matters

The report makes clear that maternity safety cannot be fixed by blaming individual staff or writing more guidance alone. It calls for system redesign, stronger accountability and a culture that listens, learns and acts.

It also makes the link between inequality and safety very clear. Racism,

discrimination, poverty, disability, poor communication and lack of trust can all affect whether women and families receive safe and compassionate care.

The report therefore supports the need for advocacy, informed consent, better communication, trauma-informed care, culturally safer services and meaningful patient and family involvement

6. Relevance to Mayah's Legacy and advocacy work

Self-advocacy

The report strengthens the case for helping women and families find the words, confidence and support to raise concerns early.

Informed consent

It highlights the need for respectful conversations about risks, options and decisions, especially where women decline recommended care.

Listening as safety

It supports the idea that listening is not a soft extra; it is central to safe care.

Anti-racism and equity

The report gives a clear basis for asking services to treat racism, discrimination and inequality as patient safety issues.

Trauma-informed support

It recognises the lasting trauma families can experience when things go wrong and the need for better psychological and bereavement support.