Baroness Amos LG CH PC, Master of University College, Oxford, has published the final report and recommendations of the Independent National Maternity and Neonatal Investigation.

After being appointed to lead the investigation by the UK Secretary of Health and Social Care in August 2025, Baroness Amos carried out the rapid investigation over a period of 10 months, supported by a team of maternity and neonatal experts.

She has found that the maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre, embed a focus on listening to women, and ensure anti-racist practice at every level.

The report highlights key areas of concern, identifies barriers to delivering change and sets out a robust package of recommendations aimed at delivering long-term systemic and cultural transformation in maternity and neonatal care for the 21st century, with accountability, equity, excellence and compassion at its core.

Baroness Amos outlines several themes repeatedly heard from women, families and staff, including women not being listened to, racism and discrimination, slow service design and planning, and inconsistent care caused by a fragmented system.

Since September 2025, the Investigation has listened directly to over 450 families from across the country and received more than 10,500 responses to a public Call for Evidence. Over 9,000 staff contributed through surveys, Trust visits and one-to-one interviews. In addition, 38 national leaders were interviewed and evidence panels were convened with national stakeholder organisations to understand system-wide challenges and solutions.

The Investigation analysed over 9,500 pieces of evidence, including data and documentation, and undertook a review of previous recommendations to understand why previously proposed changes have not been implemented or sustained. Visits to 12 NHS trusts, selected to reflect geography, socio-economic variation, trust type, case mix and feedback from families, provided direct insight into frontline care, leadership, culture and operational pressures.

The report sets out eight key recommendations to redesign the maternity and neonatal system and deliver fundamental change and identifies additional actions that can start now, which will make a significant difference to the experience of women and families and the ability of staff to provide safe care.

The National Maternity and Neonatal Taskforce, chaired by the Secretary of State for Health and Social Care, will develop and oversee a new national action plan in response to Baroness Amos’s findings.

Baroness Amos said,

“Women, babies and families deserve maternity and neonatal care that is safe, compassionate and equitable wherever they live. Too often, this Investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong.

“This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it.

“These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability, and create a system that learns when harm occurs.”

You can read the National Maternity and Neonatal Investigation report and recommendations here.

Published: 30 June 2026

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