National Maternity and Neonatal Investigation report exposes widespread failures in NHS maternity care across England

The government’s independent National Maternity and Neonatal Investigation has published its final report, describing widespread and unacceptable failures in NHS maternity and neonatal services across England.

Health and Social Care Secretary James Murray described the findings as a “watershed moment” for maternity services and the way the NHS cares for pregnant women, babies and families.

What did the National Maternity and Neonatal Investigation find?

Led by Lady Valerie Amos, the investigation examined maternity and neonatal care across 12 NHS hospital trusts in England. The review engaged with almost 11,000 women, families and bereaved parents, alongside more than 9,000 NHS staff.

The report concludes that poor maternity care contributed to avoidable stillbirths, neonatal injuries, maternal deaths and life-changing harm for babies and families.

Investigators identified systemic problems affecting maternity services across England, including:

• Women and birthing people not being listened to or believed when raising concerns.
• Racism, discrimination and unequal treatment affecting patient safety and outcomes.
• Unsafe clinical practices and inconsistent standards of care.
• Outdated systems, poor digital infrastructure and inadequate facilities.
• Workforce shortages, staffing pressures and lack of continuity of care.
• Toxic workplace cultures that discourage speaking up and learning from mistakes.
• Fragmented services and inconsistent maternity and neonatal care across NHS trusts.

Key recommendations to improve NHS maternity and neonatal care

The report sets out a series of national recommendations aimed at improving safety, accountability and quality across maternity and neonatal services.

The recommendations include:

• Establishing a statutory National Maternity and Neonatal Commissioner to oversee reform, improve accountability and drive implementation of a redesigned maternity and neonatal system.
• Embedding the voices and experiences of women, birthing people and families at every level of decision-making.
• Strengthening how NHS organisations investigate incidents, respond to harm and learn from adverse events.
• Introducing a Modern Service Framework to establish consistent national standards for high-quality maternity and neonatal care.
• Tackling racism, discrimination and health inequalities throughout maternity services.
• Strengthening governance, regulatory oversight and accountability across the NHS maternity system.
• Improving leadership, multidisciplinary teamwork and organisational culture.
• Investing in modern estates, equipment and digital systems that support safe maternity and neonatal care.

Latest maternity investigation follows Nottingham review

The publication of the National Maternity and Neonatal Investigation comes shortly after Donna Ockenden’s review into maternity services at Nottingham University Hospitals NHS Trust.

That investigation identified extensive and long-standing failures in maternity and neonatal care, concluding that repeated safety failings contributed to the deaths of mothers and babies and caused avoidable harm to many more families.

Together, the two reports present one of the most comprehensive assessments of NHS maternity services in recent years and call for urgent, system-wide reform to improve the safety and quality of care for women, babies and families across England

If you have any concerns about the maternity care that you or a loved one has recieved then please get in touch with our maternity negligence team.