National Maternity and Neonatal Investigation

Caroline Nokes Excerpts

Tuesday 30th June 2026 Commons Chamber

[The Secretary of State for Health and Social Care (James Murray)]

With permission, Madam Deputy Speaker, I shall make a statement on the national maternity and neonatal investigation.

Less than a week ago, I stood at this Dispatch Box to respond to the report by Donna Ockenden that exposed devastating failings over more than a decade in Nottingham. As many right hon. and hon. Members rightly made clear following my statement, the shocking report into what had happened was far from the first: in 2015 we learnt of the failures at Morecambe Bay; in 2022 we were appalled to hear about what had happened at Shrewsbury and Telford; and that same year the Kirkup inquiry exposed failings in East Kent. There were also other reviews and reports over the years on specific issues related to maternity care, and it is deeply upsetting to recognise that Donna Ockenden is preparing to undertake further reviews into failings in Leeds and Sussex. Despite all the warnings, the NHS is still failing women, babies and their families on a scale that shames our society.

Bereaved and harmed families are hearing once again the unbearably painful and distressing consequences of the opportunities that have been missed to put things right. As I stand here, I think of how they must be feeling. I know from meeting some of the Nottingham families that their unwavering determination is accompanied by a sense of exhaustion—a sense that however many times they have told their stories, however hard they have campaigned for justice and accountability, and however strongly they have fought to stop what happened to them from happening to others, hardly anything has changed. That feeling will be shared by mothers and their families up and down the country who have suffered so appallingly too, and there will be deep sadness and distress as they are forced to relive their trauma. The burden they bear must sit with us all.

That is why my right hon. Friend the Member for Ilford North (Wes Streeting) decided last year to announce a national investigation into maternity and neonatal services. That investigation has been carried out by Baroness Amos, whose report is published today. I put on record my thanks to her and her team for the comprehensive and compassionate way they have carried out their work.

The Amos investigation gathered evidence from more than 10,500 people, with Baroness Amos and her team personally meeting more than 450 affected families. They visited 12 NHS trusts and heard from over 9,000 staff through surveys, site visits and one-to-one discussions. Although they found that many women experience good and safe care, the report paints a bleak picture of failings at every stage for too many: from pregnancy, labour and delivery to the first hours, days and weeks after birth. When I read about those systemic failures, I found them not only shocking and upsetting but devastatingly familiar, because they are explicitly repeated in review after review. Baroness Amos found a system that is fragmented, overly complex and far too slow to learn. It needs to be radically overhauled.

Last week I spoke about the need to avoid having review recommendations accepted but then sitting on a shelf gathering dust. Other hon. Members agreed with the need to break that cycle, so that is what we will do. As I told the House last week, the national maternity and neonatal taskforce, which I chair, will create a comprehensive action plan by the end of this year.

Today’s recommendations from Baroness Amos include a proposal for a modern service framework in line with the 10-year health plan to support system change and drive consistent, quality care. Those recommendations, along with the national-level recommendations from Donna Ockenden, will feed into our plan, which will make sure that women and babies receive safe, compassionate care no matter where they live. But I do not want people to have to wait for the plan to be completed for us to start making progress, so I am also taking immediate measures in response to Baroness Amos’s investigation, which I shall now set out for the House.

In considering Baroness Amos’s recommendations, the words of a Nottingham mother I met ring loudly in my ears. She said that “accountability drives action”, so today I can confirm that, in response to these recommendations, the Government will appoint the first ever maternity and neonatal commissioner. The holder of this new statutory role will have responsibility for driving change across all parts of the NHS, including those who provide, regulate and investigate care. They will co-chair the national taskforce, along with me. They will hold the system to account, and their role will be to champion the voices of women, babies and families; to ensure that those voices are heard within Government when decisions are made and implemented.

Last week I announced that the Government would roll out Martha’s rule, so that women and their families can demand a second opinion if they feel their concerns are being ignored. That meets a key and familiar concern that the Amos investigation pointed to: women not being listened to as a common factor in maternity failings. Because those concerns are too often batted away before women even arrive at hospital, I can today confirm that we will this week publish new national standards for maternity triage, so that care is consistent across the NHS and women’s concerns are recognised, valued and acted upon at every turn. I expect every trust to prioritise the implementation of these standards and I have asked NHS England to make sure that this is the case and to report progress directly to me.

Some of the starkest examples of racism, discrimination and inequality happen in maternity and neonatal settings, as the Amos report laid bare. The result is that the risks are notably higher for some women and babies and, as Baroness Amos points out, this is a critical safety issue. Black babies are still more than twice as likely to be stillborn as white babies, and black women are almost three times more likely to die during pregnancy or shortly after birth than white women. While tackling inequalities will be a core component of the national action plan, we will make a start straightaway by rapidly expanding the roll-out of the perinatal equity and antidiscrimination programme to every trust. All teams will be mandated to receive hands-on support, to hear first-hand experience, and to undertake face-to-face learning and development programmes. Every trust will have completed the programme by the end of next year.

Births that are safe for mothers and babies depend on health services having skilled, trained midwives. As Baroness Amos rightly identified, staff shortages can have a dangerous impact, with examples of some services being forced to delay admissions when they get too busy. Since coming to office, we have recruited 2,000 more midwives, and last year our graduate guarantee gave 850 more newly qualified midwives an immediate route into the profession. I can tell the House today that we have now created a further 1,000 temporary roles to help newly qualified midwives join the NHS. These new posts will be accompanied by investment, too, and I can confirm that we are investing an extra £41 million, on top of the £145 million already invested, to upgrade outdated and rundown maternity and neonatal facilities.

Alongside these practical measures comes a far more profound challenge that we must face. It is clear from my conversations with affected families, with Donna Ockenden and with Baroness Amos, and from the findings of all the reports, that culture is where so much of the responsibility lies. That culture is the most deep-rooted cause of the failures we have seen, and the most fundamental thing we must change. We know that when families have been in distress and looking for answers, they were too often ignored, sneered at, disbelieved, blamed and lied to. We know from review after review that wrongdoing is covered up and that bullying towards staff who try to sound the alarm is rife, so we will dismantle toxic dynamics, boost staff morale and support better teamwork between midwives, doctors and other clinicians.

We need not only the right policies, procedures and processes to be in place, but a fundamental reset in the culture of a service that too often puts the desire to protect itself above its duty to protect women and babies. That culture change must come from the top. It is time for trust leaders, executives and senior clinicians to pay attention to what is happening on their watch, to put professional tribalism aside, to lose the bunker mentality when things go wrong and to ensure that the safety of women and babies always comes first.

This has to be a watershed moment. We must break the cycle of recommendations sitting on a shelf gathering dust. We cannot go on having review after review while women and babies, as well as their fathers and other family members, continue needlessly to suffer injury, death and lasting trauma. We should all feel a responsibility to ensure that this opportunity is not squandered. We owe nothing less to every family the NHS has failed in the past, and to every family who will rely on it in the future. I commend this statement to the House.

[Madam Deputy Speaker (Caroline Nokes)]

I call the shadow Secretary of State.

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[Several hon. Members rose—]

[Madam Deputy Speaker (Caroline Nokes)]

Order. Before I call the next Member, I wish to say three things. First, the Secretary of State for Defence will commence his statement at 2.30, so time is limited; Members may help each other if they ask short questions. Until then, the Macmillan Room in Portcullis House and Committee Room 7 are available as reading rooms for the defence investment plan. The plan will be made available from the moment that the Secretary of State for Defence begins his statement at 2.30.

[Wes Streeting (Ilford North) (Lab)]

May I add my thanks to Baroness Amos? I join the Secretary of State in emphasising the importance of culture change, but culture change will not happen without accountability. In all the conversations I had with families who were suffering bereavement, harm to themselves or harm to their children, what shocked me most was the cover-up culture in the NHS, which persists to this day, and was exposed once again by Donna Ockenden in her report last week.

There is a legitimate debate to be had about whether we continue with place-based inquiries or have a national statutory public inquiry, and we must have that debate. But whatever the answer to that question, any report will be worth the paper it is written on only if all those involved in decision making and care are held to account through a duty of candour. Given that, where is the Hillsborough law? The law is important not just for justice for the 97, but for justice for these families and in preventing future harms. Will it at least go through this House before the summer recess? Until it is on the books, people will continue to duck the real questions.

[James Murray]

I thank my right hon. Friend for his comments, and again put on record my thanks and tribute to him for having initiated the investigation that Baroness Amos published today. He has been a committed champion of change in maternity services in this country.

I could not agree with my right hon. Friend more about the importance of accountability in culture change. Without accountability, we will not have culture change across maternity services, and the culture of cover-ups will continue. Senior clinicians will feel that they can continue to get away with any mistakes. They will feel that they can avoid scrutiny when investigations take place, and will continue, in too many cases, to be more concerned with protecting themselves than with protecting women and babies.

On what we can do to change that culture, culture is deep-rooted and requires us to take a number of different actions, but the duty of candour is the single most powerful change we can make clearly, loudly and publicly, because the message it will send to senior clinicians thinking about what to do in the future if they make a mistake, or if they are tempted to cover up things that go wrong, is that one day they will be held to account, and there is no avoiding that. With a duty of candour in place, there will no longer be an opportunity for clinicians, in particular senior clinicians, to refuse to engage in that process, to refuse to be held to account and be part of the justice process. People will face up to two years in prison if they refuse to co-operate, so it is a serious measure. I very much agree with him on the importance of ensuring that the Hillsborough law gets on the statute book so that this duty of candour can apply to future maternity investigations.

[Madam Deputy Speaker]

I call the Liberal Democrat spokesperson.

[Helen Morgan (North Shropshire) (LD)]

May I also add my thanks to the Secretary of State, to Baroness Amos and her team, and to the families that have relived the pain of their experiences to bring about this report? But the Amos report tells us little that we did not already know—indeed, it confirms our worst fears. Maternity services in England are fundamentally broken with the cost of political neglect being paid in trauma, injury and lost lives. Figures revealed by the Liberal Democrats in the last week show that the first quarter of 2026 saw the worst rate ever recorded for maternity injuries. In fact, while the number of reviews into NHS maternity services has steadily ticked up, we have also seen rising maternal mortality rates.

Four years ago, I spoke in this Chamber in response to the findings of the Shrewsbury and Telford review, which were devastating for my community. Last week, I stood here really distressed, actually, as we heard further traumatic reports from the Nottingham review. But anger is not enough. The Government must meet this moment now and implement Baroness Amos’s recommendations in full and without delay, or the families simply will not forgive them. To do this, we need genuine accountability through the NHS and the Department of Health and Social Care, accompanied with the investment needed to make Britain the safest country in the world to have a baby.

I welcome the Government’s commitment to a national maternity commissioner—a long-standing Liberal Democrat campaign—and the other urgent and immediate actions that the Secretary of State has outlined in the last week. They are all urgent and are signs that this is being taken seriously. But we need to recognise that a commissioner alone cannot fix the broken system. I urge the Secretary of State to work with us and look at our maternity rescue package for inspiration for his action plan—it has a great degree of overlap with Baroness Amos’s recommendations. Our package would ensure one-to-one midwifery care for every woman in labour, additional senior midwives, an obstetrician on every ward, and mandatory updated annual training. Will the Government commit here and now to implementing all those recommendations and working with us to deliver the change we need?

[James Murray]

I thank the hon. Lady for her comments, and she puts it well when she talks about Baroness Amos’s investigation confirming our worst fears. I was shocked but not surprised, sadly, to read the investigation report. It was devastatingly familiar to read what it set out as being the failings across the country. The report’s recommendations will now become part of the work of the taskforce, which I chair, to produce the comprehensive action plan by the end of this year. My intention is that the taskforce will take all the national recommendations from Baroness Amos’s report, as well as the national-level recommendations from Donna Ockenden’s report last week and recommendations from any other investigations and reports, and ensure that the action plan it produces comprehensively addresses all the issues raised. I think that we would all agree that there is not—one, two, three—a small number of actions that we need to take; this has to be a comprehensive plan to truly transform the service.

[Madam Deputy Speaker]

I call the Mother of the House.

[Ms Diane Abbott (Hackney North and Stoke Newington) (Ind)]

The Secretary of State will know that many women are never more vulnerable than in childbirth. It is about not just the vulnerability, but the horror of what women and their babies are exposed to in childbirth. We see inquiry after inquiry, and nothing seems to improve. Very many of those who suffer during childbirth are black women and their babies. The Secretary of State said himself that

“Black babies are still more than twice as likely to be stillborn than white babies, and black women are almost three times more likely to die during pregnancy or shortly after birth than white women.”

The whole House wants to see progress, but it is not enough to have another inquiry or another report; what black women want is equity of treatment and fewer black women and their babies dying.

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[James Murray]

My hon. Friend draws out an important point: a key part of developing the national action plan is to ensure we have the right metrics and mechanisms for monitoring its implementation and the right structures in place to make sure it is implemented across all trusts. In working with members of the taskforce, I will ensure that those accountability mechanisms for the delivery of the plan are in place, because I have spoken many times today about the importance of recommendations not sitting on shelves. We need to ensure we have the structures in place such that the actions in the national action plan are implemented, we can see they are being implemented, and we can give people confidence that that is the case.

[Madam Deputy Speaker (Caroline Nokes)]

I call the Chair of the Health and Social Care Committee.

[Layla Moran (Oxford West and Abingdon) (LD)]

I, too, thank Baroness Amos, her team and, most especially, the families who so bravely gave the evidence that has formed this report. Further to the conversation about accountability, the Secretary of State will have noticed that some families are concerned that the commissioner is just one person, and that there is too much for them to do. Can he make clear that the buck stops with him and, indeed, the PM, and that he will not let go of this? The commissioner will report every six months to the Health and Social Care Committee—we welcome that—and once a year to Parliament. Further to that, will he personally commit that the Secretary of State will seek permission from Mr Speaker to make a statement to the House once a year, so that they can be held personally accountable for the progress made too?

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[James Murray]

I will take away the right hon. Gentleman’s suggestion and think on it, because it is critical that we have accountability. As I said in response to earlier questions, I find the decision of senior clinicians not to take part in the Nottingham inquiry utterly unacceptable, and incomprehensible on a personal level. We must ensure that that never happens again.

[Madam Deputy Speaker (Caroline Nokes)]

I call Dr Ben Coleman.

[Ben Coleman (Chelsea and Fulham) (Lab)]

I am not a doctor, but thank you so much, Madam Deputy Speaker. Perhaps I am a doctor from the university of life—who knows?

I pay tribute to Baroness Amos for this excellent report, and to my right hon. Friend the Member for Ilford North (Wes Streeting) for commissioning it. It is a remarkable piece of work. It follows on from Ockenden, and the report on black maternal health done by my Health and Social Care Committee—its Chair, the hon. Member for Oxford West and Abingdon (Layla Moran), sits on the Opposition Benches. We see the same problems again and again: misogyny, racism and a lack of accountability. I am therefore delighted that this plan will be developed in six months, through the taskforce, and that we will have a maternity commissioner. I know that my constituent Louise Thompson, who has been campaigning hard for this position to be created, will be delighted. However, like me, I think she will have a question about timing. Will it be possible for the commissioner, who will be introduced on a statutory basis, to be brought in quickly enough for them to have a full role in shaping and creating the plan that will be before us in six months? If not, why not?