In June, Health and Social Care Secretary, Wes Streeting, announced a rapid national investigation into NHS maternity services to improve care and safety urgently. Baroness Amos will be leading the investigation.
This week, 14 hospitals at the heart of a rapid national investigation into maternity and neonatal services ordered by the government have been named. In addition, the terms of reference of the investigation were published. Investigators will explore how they look after women and their babies and the Trusts were selected to ensure investigators can learn lessons from right across the NHS, covering different types of hospitals and demographics across the country.
The investigation will look at a range of services across the maternity system. Women and families will speak directly to investigators, ensuring their voices are heard and their experiences drive recommendations. The investigation will run alongside a National Maternity and Neonatal Taskforce – made up of a panel of experts and families. The aim is to address several issues facing maternity care in England – including inequalities facing women from Black, Asian and deprived backgrounds.
Alongside the Health and Social Care Secretary, Baroness Amos has agreed on the scope of the inquiry, which will include understanding the lived experiences of families and of healthcare professionals, reviewing the quality and safety of services, identifying the drivers and impact of inequalities and identifying barriers to making improvements.
Following its conclusion, she will deliver one clear set of national recommendation to achieve consistently high-quality, safe maternity and neonatal care, with interim recommendations delivered in December 2025.
The terms of reference state that the investigation “will have a particular focus on the experiences of women, babies and families as they engage with all stages of the maternity and neonatal care pathway.” This is defined to include: pre-pregnancy advice and care; pregnancy care; and care and support including bereavement care for adverse outcomes (such as miscarriage, stillbirth, perinatal, and maternal morbidity and mortality).
Health and Social Care Secretary Wes Streeting said:
“Bereaved families have shown extraordinary courage in coming forward to help inform this rapid national investigation alongside Baroness Amos.
“What they have experienced is devastating, and their strength will help protect other families from enduring what they have been through.
“I know that NHS maternity and neonatal workers want the best for these mothers and babies, and that the vast majority of births are safe and without incident, but I cannot turn a blind eye to failures in the system.
“Every single preventable tragedy is one too many. Harmed and bereaved families will be right at the heart of this investigation to ensure no-one has to suffer like this again.”
Baroness Valerie Amos said:
“It is vital that the voices of mothers and families are at the heart of this investigation from the very beginning.
“Their experiences – including those of fathers and non-birthing partners – will guide our work and shape the national recommendations we will publish. We will pay particular attention to the inequalities faced by Black and Asian women and by families from marginalised groups, whose voices have too often been overlooked.
“Our aims are to ensure the lived experiences of affected families are fully heard, to conduct and publish 14 local investigations of maternity and neonatal services, and to develop recommendations informed by these that will drive improvements across maternity and neonatal services nationwide.”
Munira Oza, Chief Executive of The Ectopic Pregnancy Trust, commented:
“We recognise and pay tribute to the efforts and energies of women, parents, and families, sharing their difficult experiences to effect change.
The terms of reference states that the investigation will cover all stages of the maternity pathway – including pregnancy care and care and support for adverse outcomes like pregnancy loss and maternal morbidity and mortality.
Many previous reports have emphasised the need to learn crucial lessons when it comes to care for women experiencing ectopic pregnancy. Most pregnancies continue smoothly and safely. However sadly some do result in harm or loss.
This investigation must reveal and address the gaps that still remain so that women are spared harm and risk of death due to ectopic pregnancy and get the care that they need after loss.
It is vital for this investigation to progress quickly and efficiently and for robust, meaningful actions to follow swiftly. Healthcare teams should also be supported through the investigation phase and implementation of recommendations. We would wish to see clear steps, identifying barriers and opportunities for improvements and examples of good practice. With these pillars alongside vital investment, we can develop a strong maternity system, putting safety and empathic care at its core.”
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