Baroness Amos, who is leading the national Independent Investigation into Maternity and Neonatal Services in England, published her interim report Reflections and Initial Impressions on 9 December 2025, outlining the initial findings.
The investigation, which has heard from families and NHS staff, found that women and families have received and continue to receive “unacceptable care” leading to “tragic consequences”, whilst “staff have faced death threats.”
Whilst the report acknowledges that some families have received “high-quality, compassionate care”, the report also identified around nineteen key themes impacting on safety and learning, including:
- lack of communication and support from clinical teams and organisations
- lack of family engagement in reviews of care and feedback of review reports
- women’s knowledge of their own bodies and important information essential to clinical decision making about their care, such as reduced fetal movement, sometimes being disregarded
- birth plans not being read or followed, leading to women not being cared for in the way they wanted or had agreed, as well as having to repeat their wishes multiple times
- the impact of discrimination against women of colour, working class women, women with mental health challenges and younger parents leading to poorer outcomes
- fathers and non-birthing partners feeling unsupported
- an overly legalistic, adversarial approach when concerns or complaints are raised
Next steps
For the remainder of December 2025 and in January 2026, visits to the trusts included in the Investigation will continue. Initial findings following the conclusion of site visits will be published in February 2026 to help to ensure that the Maternity and Neonatal Taskforce is able to consider local findings.
In addition, Baroness Amos will launch a Call for Evidence for families in January 2026 and consult with key national organisations, such as the Care Quality Commission, Royal College of Obstetricians and Gynaecologists, Nursing and Midwifery Council and Royal College of Midwives.
The investigation will also review of the legal framework regarding the role of coroners in relation to stillbirths and compensation arising from harms sustained from clinical negligence.
In due course, the investigation will set out one set of national recommendations to improve the maternity and neonatal care, which will be included in the final report in February 2026. The review is a real opportunity for change and systematic improvement across maternity and neonatal services for the benefit of women, babies, families, staff and services as a whole.
Rollout of Maternity Outcomes Signal System
Alongside the maternity and neonatal investigation, and as part a continuing commitment to improving maternity care, NHS England recently announced the rollout of a first-of-its-kind real time safety signal system that supports early detection and responses to potential safety issues, including patterns in maternity data which seems out of the ordinary and will send a warning signal to the unit indicating a safety check should be carried out urgently.
It is early days for the online Maternity Outcomes Signal System (MOSS) which is now being rolled out across all maternity services in England and Wales and will operate seven days a week. The data and signals will be visible at trust, Integrated Care Board and regional and national level, ensuring transparency and rapid action from ‘ward to board’.
NHS England states, “once a signal is generated, it is mandatory for the maternity unit to carry out a critical safety check within eight working days and share action taken with regional and national teams.”
Retrospective analysis has showed that MOSS would have detected patient safety issues in maternity units that later experienced serious incidents, including East Kent, Shrewsbury & Telford, Leeds, and Nottingham. The new tool is expected to help identify serious safety issues and prevent tragedies in the future.
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