A Turning Point for Maternity and Neonatal Safety: Publication of the National Maternity & Neonatal Investigation Findings and Recommendations 

Today, Baroness Amos published the final report and recommendations from the independent National Maternity and Neonatal Investigation. The investigation brings together the experiences of families, healthcare professionals, and maternity and neonatal services across England, and aims to deliver long-term transformation in maternity and neonatal care. The review concludes that, though many families do have a good experience, maternity and neonatal services are not consistently delivering safe, equitable, high-quality or compassionate care.  The report found that the challenges facing services are systemic rather than isolated to specific organisations. 

Behind the findings and recommendations are deeply personal stories of loss, harm, trauma and resilience, and it is important that those experiences continue to be acknowledged and respected as an action plan is put into place. 

Key findings from the Final Report and Recommendations 

The report highlights a number of recurring themes across maternity and neonatal services: 

• Women and families are too often not listened to, heard or believed when they raise concerns, with significant consequences for safety and experience
• Racism, discrimination and inequalities continue to affect both experiences of care and outcomes for women, babies and families 
• Workforce pressures, staffing shortages and rising complexity of care are placing considerable strain on services 
• Culture, leadership, governance and accountability require significant improvement to support safer care 
• The review recommends the appointment of a national maternity commissioner and the development of a national action plan to help drive change across the system.  

Our reflections 

Baby Lifeline submitted evidence to the National Maternity and Neonatal Investigation team in March 2026. Our submission brought together thoughts from our Multi-Professional Advisory Panel and Family Voices Group, and focused on the structural and cultural changes needed to ensure that maternity and neonatal services consistently deliver safe, compassionate and equitable care. We were pleased to see that today’s National Maternity and Neonatal Investigation Final Report supports our suggestions regarding workforce pressures, culture, training, learning from harm, inequalities, fragmentation of care, and infrastructure improvements. 

The central message of today’s report is that, though there are many recommendations for improving maternity and neonatal care in England, there has been a lack of consistent implementation, accountability and sustained system change. As we reflect on the findings, our focus is on what needs to happen next. 

From insight to implementation 

The next six months could be a turning point for maternity and neonatal care. The UK government has committed to developing a national action plan, overseen by a new national taskforce that brings together organisations and experts from across maternity and neonatal care, with diverse perspectives and areas of expertise. This creates an opportunity to move beyond identifying problems and focus on how improvements can be delivered, measured and sustained across the system. 

Baby Lifeline is pleased to be contributing to this next phase of work through our involvement in a taskforce expert reference group. 

This focus on implementation will also be at the heart of our National Maternity Safety Conference this September. Identifying challenges is only the beginning.: the priority now is to understand how improvements can be delivered, sustained, and embedded within everyday practice. 

Investment remains crucial 

We welcome the £41 million investment to improve safety at maternity and neonatal facilities announced alongside today’s publication. However, investment must be sustained and go beyond addressing the most immediate challenges.   

We have found that healthcare professionals lack the time, training, equipment, or resources needed to provide the safest care possible. Improving maternity and neonatal safety requires investment in staff, training, infrastructure, equipment, leadership and service design. 

Baby Lifeline’s CEO and Founder, Judy Ledger MBE, said: 

“The publication of this report and what will follow is a key turning point for maternity and neonatal safety. The report is clear that action is needed to improve maternity and neonatal care for everyone, and this includes implementation, accountability, sustained action, and funding. The experiences shared through the investigation are deeply significant, and it is important that the voices of both families and healthcare professionals continue to be heard as we move forward. 

We welcome the development of a national action plan and taskforce, both of which provide a crucial opportunity to bring together families, professionals and organisations from across the sector to focus on next steps to improve care. We look forward to being part of that work. 

We remain committed to supporting the implementation of improvements, and to working collaboratively with families, professionals and policymakers to ensure that maternity and neonatal services deliver the safe, compassionate care that every family deserves.”