In September 2025, the Department of Health and Social Care announced that 14 NHS hospital trusts, including University Hospitals of Leicester NHS Trust, would be the focus of a rapid, independent national investigation into maternity and neonatal services.
The National Maternity and Neonatal Investigation is being chaired by Baroness Valerie Amos, a former UN diplomat. It has been described as both a family-centred review of the lived experience of women and babies and an urgent look at the systemic failures, which cause so many preventable tragedies in maternity care. It is hoped that the rapid review will lead to a single set of national recommendations being created, which will aim to improve safety and reduce inequalities in care across maternity services.
What has happened since the National Maternity & Neonatal Investigation started?
Shortly after the investigation was announced, 2 of the hospital trusts involved were removed. It was confirmed that Leeds Teaching Hospitals NHS Trust would be subject to a separate, standalone maternity enquiry, so it was removed from the national investigation.
Shrewsbury and Telford Hospital Trust was subject to an in-depth investigation chaired by Donna Ockenden between 2017 – 2022, which looked at the standard of its maternity care from 2000 onwards. It was removed from the national investigation to protect the integrity of an ongoing police investigation.
December 2025 - initial impressions & reflections
In December 2025, Baroness Amos published her reflections and initial impressions from the first 3 months of the investigation. By that time, she had visited 7 hospital trusts and had spoken with 170 families. She said that what she had seen was “much worse” than she expected.
Some of the women she spoke to felt that they had been blamed for their baby's death. They also said that they were not listened to, and women from Black, Asian and marginalised communities reported that they felt that they had been discriminated against.
Baroness Amos also heard about a lack of cleanliness in hospitals, women not receiving help to go to the bathroom or to empty their catheters, or not being given meals.
One of the most concerning reflections was that NHS trusts “mark their own homework” in cases where babies have died. This called into question whether families can ever trust the answers they receive from hospital trusts without an independent investigation.
January 2026 – Call for Evidence opened
In January 2026, the Investigation opened its public Call for Evidence. The responses received from the Call for Evidence will help the Investigation team to produce findings and recommendations about maternity care in England.
Women and families are asked to share their experiences of poor maternity care in online surveys. The Call for Evidence is open until 17 March 2026.
Click the link to share your experience of maternity care – Link to Call for Evidence.
What does the Interim Report say?
The Interim Report for the National Maternity & Neonatal Investigation has been released today. Baroness Amos writes that since the initial impressions and reflections reported in December 2025, she has had “significant further engagement” with women, families, community organisations and staff.
She and her team have met with over 400 family members and the Call for Evidence has had over 8000 responses to date.
The purpose of the Interim Report is for Baroness Amos to share the insights that she has gained so far, reflecting what she and her team have been told by families and staff, and also what the investigation team has seen.
She is clear that the experiences that have been reported have continued to have consistent themes including:
- Families being disregarded.
- Women and families not being listened to.
- A lack of kindness and compassion.
- Reluctance by hospital trusts and professionals to admit mistakes and say sorry.
Baroness Amos discusses the lack of consistency in the provision of maternity care and describes the system as looking “fragmented”. She says that the system “is not working for women, babies and families, or for staff”.
She notes the wider impact of failures within the maternity system including on people’s mental health, employment and schooling performance, ability to access social care and welfare, and on relationships.
Baroness Amos knows that it has been asked what will make the National Maternity & Neonatal Investigation different to the maternity investigations that have gone before it. She responds to say that the Investigation is national in scope and “takes a whole system view – looking at people, culture, organisation, processes, infrastructure and the wider factors impacting on the care delivered by maternity and neonatal services.”
She sees the purpose of the Investigation as understanding and identifying the urgent systemic issues with maternity care that need to be addressed.
Inequalities in maternity care for Black and Asian families
A notable difference in the National Maternity & Neonatal Investigation and other maternity investigations is that it will pay “particular attention” to examining why Black and Asian families have noticeably poor outcomes in maternity care.
In the Interim Report, Baroness Amos writes of her great concern about the reports of racism and discrimination from maternity staff towards families, between maternity staff, and from families towards maternity staff.
The higher risks of adverse outcomes for women and babies from Black and Asian backgrounds and women living in more deprived areas have been reported for several years. National data from MBRACCE-UK consistently reports that:
- Black women are almost 3 times as likely to die during pregnancy or up to 6 weeks after delivery, compared to White women.
- Asian women are 1.3 times more likely to die during the same period.
- Women from deprived backgrounds have twice the rate of national mortality than those in the least deprived areas.
- Babies of Black ethnicity are more than twice as likely to be stillborn.
- Neonatal mortality rates are higher for Black and Asian babies when compared with White babies.
These statistics sadly continue, with no indication that anything will change anytime soon.
What factors are contributing to poor maternity care?
The Interim Report sets out 6 factors that could be contributing to the “pressures on the maternity and neonatal system”. They are:
- Capacity pressures. Issues include: antenatal appointments not being long enough for meaningful discussions, lengthy waiting times for assessment in hospital, delays to admissions or inductions due to understaffed antenatal wards or delivery units, disruption to community care because community midwives are drafted in to cover delivery units, missing or incomplete records causing delays.
- Culture and leadership. Accounts were given of poor relationships between team members in maternity and neonatal teams. Clinical leaders are not given sufficient training, time and support, which prevents them being effective. Ineffective management of poor behaviour by senior clinicians is causing frustration and poor morale. The public scrutiny on maternity care is impacting staff and is said to be contributing to burnout.
- Racism and discrimination. The investigation team heard about racial stereotypes being used in maternity and neonatal services, which impact how they are treated and managed by maternity staff. Community organisations reported that the racism and discrimination experienced by some families can result in their trust in the system being eroded because they feel that it is “not for them”. Many families felt that attitudes fall far short of what is expected and many reported a lack of sensitive and culturally competent communication. Staff also reported experiencing racism from families accessing maternity care.
- Poor responses and lack of accountability when things go wrong. There were many reports of lack of compassion following incidents that resulted in harm, lack of transparency about what had happened, no clear communication or learning when things had gone wrong. Many families felt that the truth had been covered up or that they had been met with a defensive attitude when asking questions about what had happened to them or their baby. A big concern was also that investigations do not appear to have led to improvements in care.
- The quality of estates. The NHS Trusts visited are delivering maternity and neonatal services in estates that are “outdated and dilapidated.”
- Workforce. It is reported that maternity units do not feel consistently safely staffed.
What happens now?
The Interim Report confirms that the maternity system is not working for women, babies and families.
The next phase of the Investigation will include the following steps:
- Continue to analyse previous recommendations to improve maternity care.
- Evidence gathering from national stakeholder organisations to give insights into organisational structures.
- Hold evidence panels that will focus on inequalities, system-wide working and the relationship between hospital trusts and families.
- Continue to consider responses from families and staff to the Call for Evidence.
The Investigation team will analyse all of the evidence so that it can provide a set of national recommendations with the purpose of driving improvements in maternity and neonatal services in England.
A National Maternity and Neonatal Taskforce will then be created, which will design and deliver an action plan based upon the Investigation’s findings and recommendations.
The final report from the Investigation will be released in April.
Quote from author Gemma Lewis, Partner and Specialist Medical Negligence Solicitor from MDS, said "The findings from the National Maternity & Neonatal Investigation Interim Report come as no surprise to anyone who has been following the story of the failing maternity services in England for years now. At the very least, every family must receive safe and compassionate care in a maternity and/or neonatal setting and must receive answers when things go wrong. The cycle of repeating the same mistakes, which lead to more tragedies, must be broken.”
