National maternity investigation launched to drive improvements

A rapid national investigation into NHS maternity and neonatal services has been ordered by Health and Social Care Secretary Wes Streeting to provide truth and accountability for impacted families and drive urgent improvements to care and safety, addressing systemic problems dating back over 15 years.

This government inherited a situation where issues in maternity and neonatal care had been ongoing for some time and a series of independent reviews into local trusts had found similar failings in compassionate care - including the failure to listen to women, concerns over safety, and issues with leadership and culture.

The investigation will urgently look at worst-performing services in the country, but also across the entire maternity system, bringing together the findings of past reviews into one clear national set of actions to ensure every woman and baby receives safe, high-quality and compassionate care. 

Crucially, it will be co-produced with clinicians, experts and parents all feeding in, following a series of private meetings last week between the Secretary of State and families who have been harmed or bereaved by failures in their care. It will begin its work this summer and report back by December 2025. 

The investigation comes alongside a package of immediate actions to improve care, including greater intervention by the Secretary of State and NHS chief executive to hold failing trusts to account - a key step in delivering the government's mission to build an NHS fit for the future through the Plan for Change.

Health and Social Care Secretary Wes Streeting said: 

For the past year, I have been meeting bereaved families from across the country who have lost babies or suffered serious harm during what should have been the most joyful time in their lives.  

What they have experienced is devastating – deeply painful stories of trauma, loss, and a lack of basic compassion – caused by failures in NHS maternity care that should never have happened. Their bravery in speaking out has made it clear: we must act – and we must act now. 

I know nobody wants better for women and babies than the thousands of NHS midwives, obstetricians, maternity and neonatal staff, and that the vast majority of births are safe and without incident, but it's clear something is going wrong.

That's why I've ordered a rapid national investigation to make sure these families get the truth and the accountability they deserve, and ensure no parent or baby is ever let down again.  I want staff to come with us on this, to improve things for everyone.

We‘re also taking immediate steps to hold failing services to account and give staff the tools they need to deliver the kind, safe, respectful care every family deserves. 

Maternity care should be the litmus test by which this government is judged on patient safety, and I will do everything in my power to ensure no family has to suffer like this again.

The investigation will consist of two parts. The first will urgently investigate up to 10 of the most concerning maternity and neonatal units, including Sussex, to give affected families answers as quickly as possible. 

The second will undertake a system-wide look at maternity and neonatal care, bringing together lessons from past inquiries to create one clear, national set of actions to improve care across every NHS maternity service.

The government is also today establishing a National Maternity and Neonatal Taskforce, chaired by the Secretary of State for Health and Social Care – and to be made up of a panel of esteemed experts and bereaved families.

Sir Jim Mackey, Chief Executive at NHS England, said:

Despite the hard work of staff, too many women are experiencing unacceptable maternity care and families continue to be let down by the NHS when they need us most.

This rapid national investigation must mark a line in the sand for maternity care - setting out one set of clear actions for NHS leaders to ensure high quality care for all.

Transparency will be key to understanding variation and fixing poor care - by shining a spotlight on the areas of greatest failure we can hold failing trusts to account. Each year, over half a million babies are born under our care and maternity safety rightly impacts public trust in the NHS – so we must act immediately to improve outcomes for the benefit of mothers, babies, families and staff.

Kate Brintworth, Chief Midwifery Officer for NHS England, said:

Through this rapid investigation and the immediate actions announced today, we are determined to transform services so that every family receives safe, personalised and dignified care at one of the most significant and vulnerable times in their lives.

We know we have significant issues to address concerning safety and culture within maternity and neonatal services, and Black and Asian women and those in deprived areas still face worse outcomes, so we must redouble our efforts to improve care for all.

The overwhelming majority of births in England are safe, and I'd urge all women to engage with their maternity service and raise any concerns they may have about themselves or their baby. Every birth matters and we will work to ensure all families trust their local NHS and feel supported through their maternity journey.

This will address several issues facing maternity care in England. One area of focus will be addressing the devastating inequalities that women from Black, Asian and deprived backgrounds face. It will also look at a lack of compassionate care and concerns over safety.

Speaking at the Royal College of Obstetricians and Gynaecologists (RCOG) World Conference today, the Secretary of State will outline a series of measures to immediately improve care.

This includes: 

• The NHS CEO and Chief Nursing Officer will meet with trust leaders in the areas of greatest concern, over the next month to drive forward urgent improvement, outline consistent expectations in changing culture and practice, and hold leaders to account for failing.
• A new digital system will be rolled out to all maternity services by November to flag potential safety concerns in trusts and support rapid, national action. 
• An anti-discrimination programme to tackle inequalities in care for Black, Asian, and other underserved communities. 

Dr Clea Harmer, Chief Executive, Sands:  

Sands believes listening to and learning from the experiences of bereaved parents is vital to improving maternity and neonatal care. We are pleased that the independent safety taskforce will include parent representatives.

We particularly welcome the inclusion of an anti-discrimination programme to help tackle inequalities in care for Black, Asian, and other underserved communities. Sands, along with other organisations, friends and allies, have long campaigned for this.

We look forward to working with the Secretary of State on this much-needed and long-overdue, programme and to ensuring that concrete steps are taken towards real accountability and lasting systemic change.

Vicki Robinson, Miscarriage Association Chief Executive, said:

We welcome today's announcement by the Secretary of State of a major investigation into NHS maternity services. While the scope of this inquiry is broad, we're reassured to know it will include the voices and experiences of our community – those affected by miscarriage, ectopic pregnancy, and molar pregnancy. With black women 43% more likely to experience miscarriage, it is especially welcome that these inequalities will be a key focus.

At the Miscarriage Association, we are currently conducting a UK-wide survey which aims to improve care and support during and after miscarriage. We hope the findings will provide valuable insight for this NHS investigation, to help inform and improve pre-natal care across the board. 

We hope this investigation leads to meaningful learning, and to better, more compassionate care for anyone experiencing pregnancy loss in the future.

Shauna Leven, Chief Executive Officer, The Twins Trust said:

Twins Trust welcomes the national maternity investigation. Families expecting twins, triplets or more face significantly greater risks and are sadly more likely to experience baby loss. Too often, maternity services aren't equipped to meet the specific needs of multiple pregnancies.

Our Maternity Engagement Project, which audits NHS units against NICE guidelines, has reduced stillbirths and neonatal deaths, proving that tailored care saves lives.

We urge the government to ensure families with multiples are heard. More investment is needed in staff training and resources so that maternity units can meet clinical care standards and deliver safe, compassionate care for all.

Angela McConville, Chief Executive, NCT (National Childbirth Trust) said:

This investigation has been won by the determination of bereaved families who have bravely spoken out about the devastating failures in NHS maternity care. 

The immediate investment package is a vital start to tackling deep-rooted inequalities, training frontline staff, and improving the UK's worst performing services. 

The national investigation must now move at pace to set out a clear, actionable plan for every NHS maternity and neonatal unit.

We've seen first hand the power of co-creating solutions with women and parents – real change can happen if the government listens, learns, and builds a well-resourced, safe, and equitable maternity system that works for all.

Paul Rees MBE, Interim Chief Executive and Registrar, The Nursing and Midwifery Council, said:

Every woman, baby and family has the right to expect safe and effective maternity care, wherever they are.

We welcome this rapid investigation and look forward to working with the independent taskforce and the Department of Health and Social Care to drive forward urgent improvements, and tackle the scourge of health inequalities.

Notes:

Sands is available to support anyone affected by pregnancy or baby loss, for as long as they need this. Find out more about bereavement support for parents and families, and support for healthcare and other professionals at sands.org.uk/support