While the vast majority of births in England are safe, the Government recognises that there are failings in care, including failure to learn from mistakes and provide accountability to families. These issues, coupled with stark inequalities in maternity outcomes and experience for women and babies from ethnic backgrounds and those living in more deprived areas, demonstrate that there are deep-rooted issues across maternity and neonatal services.

To help the Government understand the systemic issues behind why so many women, babies and families experience unacceptable care, the Secretary of State for Health and Social Care appointed Baroness Amos to lead a rapid, independent investigation into NHS maternity and neonatal services in June 2025. The investigation is looking into the maternity and neonatal system nationally and will bring together the findings of past reviews into one clear national set of recommendations.

The investigation will aim to understand the lived experiences of women, babies and families in England at all stages of the maternity and neonatal care pathway, which includes postnatal care and psychological support. It will also aim to understand the experiences of staff and healthcare professionals delivering care at all stages of the pathway, and how they can best be supported in providing high-quality, safe and compassionate care. To support this work, the investigation launched a Call for Evidence on 20 January 2026, which has been developed following extensive insight and feedback from families. This is a survey that is open for eight weeks, until 17 March 2026.

In December 2025, Baroness Amos published reflections on what she has heard so far as part of the investigation, following engagement with women and families. Her reflections highlighted ongoing issues experienced by women and families during their care, including a lack of communication, a lack of compassion and support when things go wrong, discrimination, and significant pressure on staff. The Secretary of State has agreed with Baroness Amos that the investigation will publish its final report and recommendations in spring 2026.

Given the investigation’s ongoing work to understand the systemic issues within maternity and neonatal services and to then make recommendations about how we should tackle this, the Government does not currently plan to appoint a Maternity Commissioner at this time.

The Government will shortly be launching a National Maternity and Neonatal Taskforce, chaired by the Secretary of State. The taskforce will take forward the recommendations of the investigation to develop a new national action plan to drive improvements across maternity and neonatal care. The taskforce will also hold the system to account for improving outcomes and experiences for women and babies.

Families’ voices will be central to the taskforce. The Secretary of State, as Chair, will allow for direct accountability – to ensure actions are implemented and issues can be raised directly with Government. The taskforce is being set up now so that it can be fully prepared to act once the investigation reports in spring.

The Government is not waiting for the investigation to report to ensure maternity and neonatal services deliver high quality care to women and babies. Immediate action is being taken to boost accountability and safety as part of the Government’s mission to build an NHS fit for the future. This includes the publication of a maternal care bundle which sets out best practice standards to reduce rates of maternal mortality and morbidity, as well as a postnatal toolkit to improve the care and support offered to women after birth. These are in addition to other programmes to tackle discrimination and racism and avoidable brain injuries.

Department of Health and Social Care