The Sands and Tommy's Joint Policy Unit has published a report today, that highlights problems with the oversight that NHS Trust boards have over the safety and quality of maternity and neonatal services.

The Joint Policy Unit reviewed publicly available board papers and minutes for seven NHS Trusts in England to analyse whether the information presented to boards, the process for review, and actions taken enabled boards to deliver on this responsibility.  

The findings across these three areas raise questions about boards’ ability to have a full understanding of the performance of maternity and neonatal units under their direction under the current system.

Responsibility ultimately lies with Trust boards which have a statutory duty to ensure the safety of care. As a result of high-profile reports and inquiries there has been a focus on having greater visibility of maternity and neonatal services at board level.

However, this review suggests that this is not leading to meaningful engagement from Boards to identify service-level issues and support improvements.


"The shocking and distressing stories emerging from the Lucy Letby case in August 2023 shone a light on the “cover-up culture” in the NHS. Although deliberate harming of babies is thankfully exceedingly rare, some of the issues raised in this case echo concerns that Trusts are failing to react to signs of poor performance in maternity and neonatal services.

"Our research raises serious questions about whether the current systems and processes enable NHS Trust boards to deliver expected oversight of maternity and neonatal service performance. Boards need clear and consistent data to enable effective scrutiny and early action to mitigate any issues identified.

"There needs to be a review of governance systems and collective effort to define what a more effective system of oversight and support which prioritises patient safety could look like."

- Georgia Stevenson, Data Evidence Lead for the Joint Policy Unit

The Sands and Tommy’s Joint Policy Unit is campaigning for stronger national action to save babies’ lives, during pregnancy and the neonatal period and on tackling inequalities in loss, so that everyone can benefit from the best possible outcomes.

Download the full report and find out more about the work of the Joint Policy Unit.

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