Baby Lifeline welcomes the publication of the Reflections and Initial Impressions report published on 9th December 2025 by the Independent Investigation into Maternity and Neonatal Services in England team, led by Baroness Amos.
The themes highlighted in the report, including poor communication, women and birthing people not being listened to, a lack of holistic care, discrimination and inequitable outcomes and adversarial response when things go wrong, are sadly all too familiar. These issues have been identified repeatedly across multiple investigations over more than a decade.
We are deeply grateful to the families who have contributed their experiences so far. We recognise the significant emotional toll that recounting such trauma brings. We also welcome the Investigation’s intention to engage with a wide range of families and community groups, including those from communities that are too often seldom heard and face entrenched health inequalities. Understanding these experiences is essential if the national recommendations are to support fair and effective change for all.
The Investigation aims to develop national recommendations to drive safe, compassionate, and equitable care – we believe this focus is vital if improvements are finally to be delivered consistently across the country. We also welcome the decision to include the perspectives of frontline staff. Those working on the frontline hold valuable insight into what is needed to improve safety and the conditions that enable, or impede, good care.
We are proud that a number experts who work with Baby Lifeline are contributing to the work of the Investigation through their roles as Expert Advisors, these include:
• Dr Bill Kirkup CBE, Baby Lifeline’s Honorary President
• Professor Alex Heazell, Course Director for Baby Lifeline’s Implementing Saving Babies’ Lives training course
• Dr Christine Ekechi, member of Baby Lifeline’s Multi-Professional Advisory Panel
What is needed now is sustained national action that addresses not only clinical practice, but the wider systems, cultures, and staffing conditions that impact on the care received by families.
Judy Ledger, Founder and CEO of Baby Lifeline, said:
“Time and again, investigations have revealed the same heartbreaking themes: families not being listened to, basic care not being delivered, and avoidable tragedies that have a lifelong impact on both families and staff. We are hopeful that this national investigation can finally drive the systemic change that families and staff so urgently need. Baby Lifeline will continue to work with families, frontline staff, and national bodies to ensure that real improvement follows.”
Baby Lifeline remains available to support the Investigation as it moves into its next phase, and we are – as always – committed to working in partnership with families and maternity professionals towards meaningful and lasting change.