Baroness Amos publishes the Independent Investigation into Maternity and Neonatal Services in England – Interim Report

In June 2025, Secretary of State for Health and Social Care Wes Streeting launched a rapid national investigation into NHS maternity and neonatal services. 

Baroness Amos was appointed to lead the review to identify and urgently improve care and safety across 12 NHS trusts. Initially, 14 NHS trusts were identified for investigation, but two were later removed. 

The plan was to review how maternity and neonatal care systems are working by combining all the recommendations from public inquiries and national investigations made since 2015. The aim was to provide a national set of actions to ensure every woman and baby receives safe, high-quality and compassionate care.  

Baroness Amos was appointed following feedback from bereaved families, who wanted someone independent from the NHS to bring ‘a fresh pair of eyes’ to the role. 

Harmed and bereaved families have played a central role in the investigation, working with Baroness Amos to shape her expert team and the review’s terms of reference.

Baroness Amos first published her reflections and initial impressions on 9 December 2025; these were preliminary observations and not a formal report of her investigations. The Interim Report presents the interim findings, and the full report (including final recommendations) is scheduled for publication in spring 2026. 

The Maternity and Neonatal Taskforce set up in January 2026, will develop and oversee the implementation of a new national action plan, based on the recommendations in the final report. 

The Interim Report is structured into two parts: part 1 summarises what the investigation has heard so far, drawing out key themes from families’ and staff experiences. Part 2 sets out the investigation’s interim analysis of the six inter-linked system factors it is focusing on as drivers of pressure, unsafe care and inequality, alongside the work planned for the next phase.

The factors identified are:

1. capacity pressures - demand and rising complexity can create delays and bottlenecks across antenatal, intrapartum, postnatal and neonatal care
2. culture and leadership - cultures of blame and fear, alongside poor multidisciplinary working, can undermine safety and compassion
3. racism and discrimination - structural and interpersonal racism affects both families and staff, contributing to poorer experiences and outcomes for Black, Asian and other marginalised communities, and those living in deprivation
4. when things go wrong families describe a lack of transparency, accountability and compassion, including reluctance to admit mistakes and provide timely explanations
5. quality of estates - outdated or poorly designed buildings can compromise dignity, infection control and the ability to deliver safe care
6. workforce - staffing shortages and retention challenges compound pressures and contribute to inconsistent care

Themes include families feeling disregarded or unheard, care that feels fragmented rather than continuous, variation in practice from trust to trust  and responses that can lack openness, accountability and compassion when things go wrong.

System pressures and workforce challenges

We know from working with experts at the Birth Trauma Association (BTA) that there are many dedicated individuals working in this field who tirelessly strive to facilitate better maternal and infant outcomes.

The system is under pressure. Midwives are feeling demoralised by underinvestment in services and the reluctance to address the discrimination which affects both clinical staff and service users. In some maternity units, there appears to be limited camaraderie within teams, with a clear demarcation between midwives and obstetricians. 

Impact on women and families 

Here at Russell-Cooke, we act for many women who are suffering from physical and emotional trauma. Many cope in silence while caring for a newborn and managing other commitments, sometimes only coming forward years after the birth, when they feel able to advocate for themselves and seek accountability.

This is a particularly sensitive time for harmed or bereaved families as these issues unfold in the media. Some of our clients need extra care during this time: many find it triggering, while others need space in order to process their experiences. Pregnant women may also experience stress and anxiety, and there is a risk that fear of trauma may become a self-fulfilling prophecy. It is essential we avoid a maternity system where traumatic obstetric and midwifery care is an expected and accepted part of having a baby in the UK. 

Driving improvements 

We recognise how raw this moment will feel for many harmed and bereaved families. The interim report underlines that improvement cannot be left to individual trusts alone: it requires action, national leadership, sustained investment and a clear expectation that maternity and neonatal teams work together openly and respectfully.  

At the same time, it is also important to acknowledge that there is good practice across the NHS, and that positive developments continue. Initiatives being trialled - including ODON and Birthglide - and the continued strengthening of evidence-based guidance for maternity emergencies (such as postpartum haemorrhage) should help to rebuild confidence.

Rachel is an associate in the personal injury and medical negligence team, specialising in medical negligence with a focus on birth injury and women’s health.