Baby Lifeline has submitted evidence to the National Maternity and Neonatal Investigation, an independent review set up by the UK government to improve safety and care across maternity and neonatal services in England.
At Baby Lifeline, we are unique in that we bring together the voices and expertise of clinicians, safety specialists, legal professionals, and families with lived experience of maternity and neonatal care. By combining professional insight with the realities families face, we’re able to identify practical, meaningful solutions to some of the biggest longstanding challenges in maternity safety.
Our submission brings together insights from:
- Our Multi-Professional Advisory Panel – clinicians, patient safety experts and legal specialists with wide experience in maternity care and investigations
- Our Family Voices Group – families with lived experience of maternity and neonatal care, including those affected by preventable harm or bereavement
We also drew on themes raised regularly through our training courses, our work at national stakeholder meetings, and through research. Overall, our submission highlights the cultural and structural changes needed to make maternity and neonatal care consistently safe, compassionate and fair.
We were also pleased to be able to share successful quality improvement work in maternity and neonatal care with the investigation, to give options for tried and tested solutions.
The seven priorities for change that we outlined in our submission are:
1. Sustainable resourcing and investment
Maternity services must have enough staff, equipment and funding to meet the needs of families they care for. Investment should support ongoing improvement, training and innovation. Staff must have their basic needs met to provide safe and high-quality care.
“We don’t have breaks or enough staff. Our basic human needs aren’t being met. People can’t be kind to each other when they’re exhausted and doing two jobs.” – Baby Lifeline Multi-Professional Advisory Panel Member
“CTG leads missing or broken. Sharing 1 thermometer between rooms. You spent more time looking for equipment than caring for women.” – Midwife
2. Workforce culture, leadership and staff support
A positive, open culture is essential for safety. Families often feel their concerns aren’t listened to, and staff can feel unable to speak up due to hierarchy, pressure or fear of blame. A safer system requires psychological safety and strong teamwork.
At our MUM Awards and 2025 National Maternity Safety Conference, Hywel Dda University Health Board shared how they improved psychological safety and reduced hierarchy in their maternity team. These changes led to better outcomes for babies, reduced staff sickness, and improved staff retention.
3. Education, training and professional development
All maternity professionals should have regular, high-quality training with their colleagues that reflects the realities of modern maternity care. Training should cover clinical skills, communication, teamwork and compassionate care.
“I am often asked to attend vital training outside my working hours and pay for it myself. The support I receive to keep my maternity skills up to date varies hugely, and for colleagues in the ambulance service it’s even more inconsistent. This lack of structured support leaves us with uneven knowledge and capability across services.” – Midwife
4. A system that learns rather than blames
How organisations respond after harm matters profoundly. Long legal processes can prolong suffering for families, and fear of blame can stop staff learning from mistakes. A safer system should be open, transparent and focused on early resolution and learning.
“Losing our baby son was devastating, but the way we were treated afterwards by the trust and other national bodies – including being dismissed, gaslit, and subjected to what we felt was a cover-up – deepened the trauma and, in many ways, was almost harder to bear than the loss itself.” – Baby Lifeline Family Voices Group member
5. Tackling inequalities in maternity outcomes
Inequalities in maternity care remain a major issue. Services must recognise individual needs and ensure fair access to safe, equitable, high-quality care for all.
“I believe that I experienced negligent care due to my ethnicity. I simply wanted dignity, compassion, and respect for life, no matter how short or vulnerable.” – Baby Lifeline Family Voices Group member
6. Improved models of care, continuity and personalisation
Teams need better coordination and ways of providing continuity of care. Women and birthing people should receive clear, personalised information about risks and choices to support them to make informed decisions.
7. Quality improvement, data and evidence
While many national programmes have aimed to improve maternity safety, their impact has been inconsistent. A stronger improvement system is needed, with better data, evaluation and involvement of families.
The National Maternity and Neonatal Investigation is a crucial opportunity to turn these insights into real change. For improvements to truly last, the system must prioritise a well-supported workforce, high-quality training, a culture that learns rather than blames, fair and equal care for every family, and models of care that are joined-up and personalised.
Baby Lifeline is committed to helping make this happen. We will continue working alongside families, professionals, and policymakers to ensure that every maternity service across the country delivers the safe, compassionate care that all families deserve.
The NMNI call for evidence for women and families is open until 5pm on 17th March 2026.