The National Maternity and Neonatal Investigation, chaired by Baroness Amos, has published its final report, concluding that the maternity and neonatal system in England is not set up to deliver consistently safe, high-quality and compassionate care.
The Investigation engaged with over 450 families, more than 10,500 respondents to its Call for Evidence and over 9,000 staff. It found that women and families are not listened to, heard or believed, in some cases leading to avoidable harm, and struggle to obtain answers and accountability when things go wrong.
It finds that racism, discrimination and structural inequalities are embedded throughout the system, with devastating consequences. Maternal mortality is almost three times higher for Black women than for White women, and Black babies are more than twice as likely to be stillborn. The report also documents discrimination against disabled women, and against families judged because of their faith, sexuality or gender identity, or social circumstances.
On leadership, the Investigation found that the quality of trust leadership has a direct impact on safety, and that poor behaviour by leaders and senior clinicians, including bullying, racism and discrimination, must be addressed.
The report makes eight recommendations:
1. A statutory Maternity and Neonatal Commissioner, reporting to Parliament and to families.
2. Listening to women, birthing people and families treated as a critical safety issue.
3. Improved quality, transparency and oversight of investigations when things go wrong.
4. A Modern Service Framework setting binding national standards across the whole care pathway.
5. Racism, discrimination and inequality treated as a critical maternity safety issue.
6. Clarified system governance and a specialist CQC regulatory unit.
7. Improved culture and teamworking, with leadership strengthened at all levels.
8. Estates and digital systems fit for modern care, backed by long-term investment.
The government has responded by announcing the UK’s first Maternity and Neonatal Commissioner, a National Action Plan to be published in December 2026, an additional £41 million for urgent facility safety risks, new national standards for maternity triage, national rollout of the Perinatal Equity and Anti-Discrimination Programme, and 1,000 funded roles for newly qualified midwives.
FNF Response
Prof Greta Westwood CBE RN, Chief Executive of the Florence Nightingale Foundation, said:
“Our first thoughts are with the women, babies and families at the heart of this report: those who have experienced avoidable harm and loss, and those who showed such courage in sharing their experiences. Much of the Investigation’s findings resonates with the findings of the Ockenden review of maternity services at Nottingham University Hospitals NHS Trust, published just last week.
We are particularly saddened by the findings on racism and discrimination and their devastating impact on the safety and care of Black, Asian and minority ethnic women and their babies. The report also lays bare the discrimination experienced by disabled women, as well as by families because of their faith, their sexuality or gender identity, or their social circumstances. Their voices must remain at the centre of everything that follows.
This is a detailed and thorough examination, and we are taking the time to examine it carefully. While the report sets out solutions across many areas, our focus will be on leadership, culture and governance, where our community of nursing and midwifery leaders can and must make the greatest difference. We will publish a full analysis of what this report means in the coming weeks, exclusively available to our FNF member community.
In the meantime, we encourage all nurses and midwives to read the report and engage with its findings. The change it calls for will depend in large part on strong nursing and midwifery leadership at every level of the system.”
