National Maternity and Neonatal Investigation
House of Lords · Lords Chamber · 6 Jul 2026 · 39 speeches · Official Report
Statement
The following Statement was made in the House of Commons on Tuesday 30 June.
“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 honourable and honourable Members rightly made clear following my Statement, the shocking report into what had happened was far from the first: in 2015 we learned 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 honourable 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 honourable 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 straight away by rapidly expanding the rollout 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”.
My Lords, I thank the Minister for the Statement and the noble Baroness, Lady Amos, and her team for the thoroughness and compassion with which they have conducted this important investigation. Above all, our thoughts must be and are with the women, babies and families whose experiences lie at the heart of this report. Many have had to revisit the most painful moments of their lives when some want to simply move on. But after years of fighting, they must be heard. Their courage, dignity, determination and persistence place a responsibility on all of us in this House. We owe it to them not simply to listen, but to ensure that their experiences finally lead to lasting change. Only last week the House considered Donna Ockenden’s devastating findings in Nottingham. Here, the noble Baroness, Lady Amos, presents us with a wider national picture. Once again, we see the same troubling themes emerge-women whose concerns were dismissed, staff who felt unable to speak up, inequalities that remained unchallenged, and organisations that failed to learn from previous mistakes. As Donna Ockenden herself observed, much of what is contained in this report is sadly already known to us, as it was to Governments of all political colours in previous years. That is perhaps the most disturbing and sobering conclusion of all. The challenge before us is no longer one of evidence. We have had inquiry after inquiry, report after report and recommendation after recommendation. The challenge now is...
My Lords, this is another week and another traumatic and difficult-to-read report about the state of maternity services. Behind it are thousands and thousands of women and families deeply affected by these service failures. I thank them all for their contributions to this report, as well as the noble Baroness, Lady Amos. Women are not being listened to, heard or believed, with serious consequences for safety and quality of care. Racism and discrimination are embedded throughout the maternity and neonatal system. Services are not responsive to the changing profile of women giving birth and the increase in medical interventions during birth. Antenatal, birth and labour, neonatal and postnatal services are just not joined up. From Somerset to Blackpool, the safety of having a baby has become a lottery. Women are silenced and staff who raise the alarm on unsafe care or systemic discrimination are crushed by a culture of fear. We need to see genuine accountability throughout the NHS and the investment necessary to make Britain the safest country in the world to have a baby. I have a number of questions for the Minister. I welcome the Government’s commitment to a national maternity commissioner, but can the Minister confirm that this post will go to an independent expert and not a political appointee? Will the Minister reassure us that action will be taken before December, rather than waiting for the taskforce to report on its plans? Will the Government guarantee safe staffing at...
My Lords, we know-and we can never acknowledge it enough-that women, babies and families across the country are being harmed, traumatised and let down by a broken system. I am grateful to both Front Benches for the way in which they have received this report and for their support, and their acknowledgement of the role we have taken in government. The noble Baroness, Lady Pidgeon, talked about trauma lasting a lifetime, and that is indeed the case. When I have met women and families who have been affected, that is what has stuck with me: the trauma never goes away. I also accept the correct challenge from the noble Lord, Lord Kamall, that the judgment will be on what has changed, not on what is written. We are very conscious of that, and I am grateful to him for reminding me of it. Before turning to the helpful questions from the noble Baroness and the noble Lord, I will make a few comments. I too want to express my gratitude to every woman, family member and member of staff who came forward to give evidence to the noble Baroness, Lady Amos, and her team, who heard from thousands of people who showed great courage and determination to share their experiences, painful though they were, and conducted their investigation with immense sensitivity and care. The noble Baroness, Lady Amos, diligently brought together evidence from families, staff, 12 local investigations and all the past reviews, and her review shows systemic, repeated failures by our maternity and neonatal system....
My Lords, I declare an interest as the chair of the Royal College of Obstetricians and Gynaecologists board of trustees. The RCOG desperately wants to see an improvement in the services that mothers and children are getting in maternity. I do not know whether the Minister is aware that some 68% of all clinicians are working hours way beyond their contracts, and 25% of them are talking about leaving the profession within five years because of a fear of burnout. Obviously, everything must be done to prevent that happening. Does the Minister agree that workforce planning is central here, including better integration between the work of doctors in maternity and midwives? There should not be barriers between the two; they should be working in units together and dealing with high-risk cases. In that context, will some decision be made pretty soon about when a redesigned workforce tool will be available for obstetricians in particular? They desperately want to see that as soon as possible and do not want to have to wait maybe as long as a year before an action plan is completed.
My noble friend allows me to say how grateful we are to the Royal College of Obstetricians and Gynaecologists for its continuing work, as we are grateful to our many partners who are committed to driving through change. We are working particularly closely with RCOG in developing routes forward. I agree with the points that my noble friend made. Most NHS maternity staff-and other staff, but we are talking about maternity staff-are providing exceptional care. It must be very difficult for them to hear about and read these findings. Our job is to support them with the right culture and leadership, and to equip them and support them to listen and learn. It is important that we have the right skills mix among consultants, to whom my noble friend refers, and retain them, because they are absolutely key. We will continue to work with RCOG accordingly.
My Lords, like others I recognise the kindness and compassion that the majority of staff in our health service deliver, but as the Secretary of State for Health and Social Care rightly said: “We must break the cycle of recommendations sitting on a shelf gathering dust”. The Minister has already made it clear that the reviews currently planned will continue. I wondered whether they might be postponed or cancelled, but, as they are not going to be, will we ensure that we stop looking further and actually implement what is necessary now, in particular more senior midwives on duty at night? As well as employing more midwives, can we look, through the NHS workforce plan, at putting both general nurses and mental health nurses on fast-track midwifery courses so that we have experts in other areas working in midwifery?
I know that the noble Baroness, Lady Amos, made the kind of comments to which the noble Baroness refers. The National Maternity and Neonatal Taskforce will certainly look at all these areas and, as I mentioned, those reviews will continue. I emphasise that we have to bring this cycle to a close. That is exactly why the former Secretary of State commissioned the noble Baroness, Lady Amos, so that we would bring together a coherent, fully informed list of national recommendations. That is indeed what we have, and we have already actioned a number of them. To the points that the noble Baroness made, that work will continue and will not be held up.
Baroness Fraser of Craigmaddie
My Lords, I will follow on from the excellent question and suggestions from the noble Baroness, Lady Watkins, about specialist nurses being fast-tracked into midwifery. Donna Ockenden’s report found that many student and newly qualified midwives feel they do not have the necessary level of skills to deal with complex cases. What conversations will the taskforce or the commissioner have with the Royal College of Midwives about the training pathway for midwives? Currently, the Royal College of Midwives does not seem to see any need for a return to nurse training.
I am fully aware of-I will put it tactfully-the difference of opinion in this regard. This morning, I was speaking with one of our main advisers, who did not feel it was necessarily an answer to go down the road of midwives being nurses-I know the noble Baroness did not say that-and I bow to that experience, but for me it raises the complexity. It is important to emphasise a point about which I have been concerned for some time: about a third of student midwives have no role to go to. The noble Baroness is right, but some of it is about basic experience, and nobody can gain experience without putting the years in-that is a fact. That is why getting the new funding, up to £10,000 per post, means we will keep students in the profession and give them the chance to develop the very important expertise to which the noble Baroness refers. Further, having multidisciplinary teams and the right people means that you can manage whatever complexity. There is no way that any one person can deal with all complex cases. Every case has a high degree of individuality, as I know the noble Baroness is aware.
My Lords, “welcome” is not quite the right term to use about these reports, but they are indeed absolutely essential. I need to declare that I am the maternity lead, as a non-executive member, at the Whittington Hospital, and I will be at the conference as a member of one of the reference groups tomorrow. Several years ago, when Donna Ockenden produced her first reports, we set up what we called the Ockenden cafes in the Whittington, to which we invited all the multidisciplinary teams, plus mums and patients and people who had been involved over a period of time; it was an enormously valuable and uplifting experience for all of us involved in the maternity care of the women in our area. However, I want to ask my noble friend about MIS, the Maternity Incentive Scheme, which is now in its eighth year and, as she will know, is designed to get maternity units to improve year by year and through that win some investment in their hospitals. Has that been factored into what might happen next?
I thank my noble friend and all her colleagues for the work they do. We have many examples across the country of first-rate care and great initiatives like the one my noble friend spoke of, which really takes on board one of the problems the noble Baroness, Lady Amos, found: that the voices of women and their families, and of staff, were just not heard or acted on. That is the one thing that comes through. To the question, would the abbreviation be MIS in this case?
Yes, MIS.
We have two “MISs” that we often talk about: MHIS and MIS. I will ensure that MIS is considered, but it is probably worth saying that we are already developing a tool for assessing the quality and experiences of care being provided for women using maternity services, through the patient reported experience measure. To the point made earlier by the noble Lord, Lord Kamall, that is one of the ways we will ensure that women and their families can actually see, feel and know the difference.
My Lords, I draw noble Lords’ attention to my registered interest as chairman of King’s Health Partners. In addition to addressing workforce concerns and driving a much-improved culture in the delivery of maternity services, the physical environment in which maternity services are delivered is critically important. These are very frequently delivered in some of the worst parts of the NHS estate in such a way that the holistic nature of the services that need to be provided is not available at a single site. Can the Minister confirm that the NHS capital budget identified for this spending period is going to be protected so that these matters might be addressed?
The noble Lord makes a very accurate observation. Perhaps I can go a bit further than he is asking me, because just last week we announced an additional £41 million of safety funding to improve the estate. That is on top of the £145 million that was previously announced, so that will give a great opportunity to really improve the estate, which is crucial for safety as well as experience.
My Lords, my sister died at birth, so I remember well the impact this has on families. What more can the Government and the NHS do to help those families who have lost a baby in such painful circumstances, or who are now bringing up a disabled child as a result of medical difficulty?
I am very sorry to hear of the loss the noble Lord experienced and of the deep effect on his family; I am sure he still lives with that feeling. I think the greatest gift we can give is to reduce the risk of something going in the way that it did in his family, and that we avoid all avoidable risks. That is exactly what this work is about, and that would be the right thing. For those who are affected, I mentioned the bereavement pathways. In terms of support that ICBs arrange across the country, there is a much greater awareness of the need to support people when they need it most.
My Lords, both the report of the noble Baroness, Lady Amos, and the Ockenden inquiry identified poor leadership cultures-defensive cultures, dismissive cultures and doctor-knows-best cultures. The noble Baroness already referred to the voices of women and their partners being ignored, particularly when they are complaining of pain. Is the Minister satisfied that the various important recommendations, provided they are implemented and seen through, will fundamentally address and change this culture?
It is a challenge to take on a deep-rooted culture, but we are doing that and it will require action at every level, without doubt. The main thing, as the noble Baroness said, is putting women, babies and their families at the heart of care. This has not been the case. NHS England’s chief executive brought all trust chief executives to London on the day the report was published to discuss the urgent actions trusts can take on this and to focus on the next 100 days. All perinatal leadership teams have also completed a culture and leadership programme, which I believe will strengthen collaboration across maternity and neonatal services. Those are just two of the actions we will take, but this is absolutely fundamental to all the system changes.
My Lords, I listened to this short debate with a bit of amazement. We are looking at the end results, but we need to look a little further up the channel. My noble friend Lady Blackstone touched on a very important point, as indeed did the noble Baroness, Lady Pidgeon, which is much more crucial than we may perhaps understand. First, as has been said, these people come to hospital not to access maternity services but to have a baby. They are not ill. That is different from the rest of the NHS, even though they are in the NHS. What we are partly seeing here is a cultural situation that is a problem throughout the NHS, not just in maternity services. It is bad in maternity services for the obvious reason that, in the main, these people are healthy, although some are not terribly fit. We are losing the plot a bit. For example, the noble Baroness, Lady Pidgeon, said that there is a need for much better psychological support, and I agree. We tend to forget that a woman who is having a baby, even a normal baby who is fully alive, is losing a life within her uterus. She feels a loss when that happens. It may not be expressed as a loss-it is expressed as happiness-but it is an extraordinary change of feeling, which psychiatrists know is very common in maternity. We forget that this affects not just women but men as well. We also sometimes assume, as we have done in this report-certain things are obvious-that it is much better not to have a caesarean section. That has been suggested,...
I absolutely agree with what my noble friend said about kindness; when we had the Statement last week, we discussed compassion as well. It is disappointing to have to talk about it, because it should be a given, but we have found that it is not. I totally agree that pregnancy is not an illness-I was once quoted as very sharply telling an interviewer that. I am not aware that it is, and it is not, but it is worth restating, in my view. On the role of men, I am very careful to speak about women and families; that is the right thing. I also clarify that, in this Statement, I do not believe anybody is suggesting that one form of birth is preferable to another. I think we would probably all agree that it is about the form that is safest and the right one for the circumstance.
My Lords, I thank the Minister for the Statement today and the noble Baroness, Lady Amos, for her excellent report. We have many reports now describing the tragedies occurring in maternity services. I hope this report will be the final one before we go back to delivering the best maternity care, as we used to. It was world leading. I am privileged to have been an obstetrician for nearly 40 years of my life, delivering many thousands of babies-normally, as people refer to it, and by caesarean sections, which are done when there is an indication to do so. We expect the mothers to enjoy normal deliveries, but also to enjoy the delivery when they must have a caesarean section. The greatest privilege I had was to hand a baby to a mother and see the first look on the mother’s face, which is unbelievable; I had the privilege to witness that first-hand, long before partners would see it. It is important that we deliver world-class maternity services and, therefore, that what the task force comes up with has the standards to be delivered. I hope it will be mandatory for those standards to be followed, monitored and audited against. It should be possible, at the mother’s first visit to the antenatal clinic, to have a plan for how her pregnancy will be managed by midwives and obstetricians. It should also be possible to have every maternity unit audited, as used to happen, when things go wrong involving the mother and the families-and to have a plan for how that will be tackled. I hope...
I am sure we were all touched to hear what the noble Lord said. It must be a privilege to have done what he has done, and to have affected so many lives-those at their beginning but also the lives of the women themselves and their families. I am sure we are all grateful to him for that. The work of the task force, and of the expert reference groups-I am so grateful to the noble Lord, as well as my noble friend Lady Thornton, for taking part in one of them-will be to develop a plan of action, not just for how it will happen but for how it will be audited. Perhaps I should say that key to all this is accountability. The Secretary of State himself said in the Statement that what stuck with him from one of the bereaved mothers he spoke to was that accountability is what drives change. Certainly, when it comes to the regulators, that is why we are also taking action to improve.