The Department of Health and Social Care (DHSC) must create a statutory Maternity and Neonatal Commissioner, introducing legislation into the Health Bill at the earliest possible opportunity, and appoint a Commissioner within six months of Royal Assent. 

What does it mean?

A new statutory maternity and neonatal commissioner would provide independent leadership to drive accountability and implement a redesigned maternity and neonatal system (through the modern service framework).

Statutory would mean that the role’s powers are granted by legislation rather than at the whim of a Secretary of State, any change to these would have to go through Parliament - so it wouldn’t be a role that could be removed overnight with a change of Government. 

How has the Government responded: 

The Government has announced the creation of a maternity and neonatal commissioner, who will co-chair the Maternity and Neonatal Taskforce. 

However, we are awaiting further details about the role, including exactly what powers they will have and how the office will be set up.

Sands response: 

We were not among the organisations calling for this ahead of publication of the report. However, when introduced the maternity and neonatal commissioner (and their office) must be established independently from Government sponsored outside the Department of Health and Social Care, as a separate non-government organisation. 

This will give the role the independence required to be critical of the Government when needed and give it the ability to hold them to account. Additionally, the commissioner role will need to be in control of its own budget with protected funding and independent publication rights to ensure the office can hold the entire system to account and provide oversight across all NHS Trusts with maternity services in England. 

DHSC, NHSE, Integrated Care Boards (ICBs) and NHS trusts must take action to listen to the voices of women, birthing people and families within 12 months.

What does it mean? 

Patient experience data/ feedback must be collected as safety intelligence data (insights collected by services to let them know how they are performing and to improve safety) ensuring that when concerning patterns emerge these are escalated to the Board with measurable improvement actions. Trusts should ensure psychological support is available to families who experience harm, separately from bereavement care.

How has the Government responded: 

The Government has not responded to these recommendations. 

Sands response:

Sands has consistently highlighted that feedback from families must be given parity with outcome data when NHS Boards and leaders are looking at the safety of their services. We know that listening to bereaved families saves babies’ lives. 

All surveys and tools capturing feedback on maternity and neonatal services must include bereaved families. However, bereaved families are excluded from the annual CQC maternity survey. The Patient Reported Experience Measure (PREM) tool for maternity and neonatal services is due to be rolled out soon, but steps must be taken to ensure this includes feedback from harmed and bereaved families (who were removed from the pilot). 

We welcome that this recommendation acknowledges the need for harmed and bereaved families to have access to psychological support. We are particularly pleased that it places a clear distinction between bereavement care and psychological support. However, with only 17% of bereaved families currently able to access the mental health care they need through the NHS this will require urgent attention from the Taskforce. Read our recommendations in Lost in the System here: sands.org.uk/sites/default/files/Sands_Mental_Health_report_Lost_In_The_System_2025.pdf

DHSC, NHSE and CQC must drive improvement, within 12 months, of the quality, transparency, oversight and accountability of investigations and ensure learning is captured and acted upon when things go wrong.

What does it mean? 

This recommendation acknowledges the imbalance of resources available between trusts/ hospitals and bereaved families. This imbalance may prevent families getting answers when their baby dies. Investigations must include independent challenge at every stage (to stop hospitals marking their own homework without external oversight), and the quality of reviews should be included in CQC assessments. If a family is unhappy with the outcome of a trust review or investigation, they should be able to ask for the trust to commission an independent investigation. 

There should be a national specialist training programme for investigation staff to ensure they have the skills and time to complete reviews or investigations to a high standard and communicate with families and staff. Whilst learnings should be shared nationally and locally. 

How has the Government responded: 

The Government has not responded to this recommendation. 

Sands response:

The current review and investigation process does not work for bereaved families. Too often, it is a process which happens to families rather than with them - when it should be centring them.

Review and investigation processes are overly complicated, disjointed and difficult to navigate. Too often they exclude families’ experiences, exacerbating their trauma.  They also fail to deliver the learnings they were designed to with too little oversight from external parties. 

This recommendation does not go far enough. Review, investigation and complaint processes need a complete overhaul. All investigations and reviews should be completed through a single parent pathway, which centres families and ensures accountability. This should join up seamlessly with complaints and feedback processes.  

DHSC/NHSE must design a Modern Service Framework for maternity and neonatal services within 12 months and begin rollout within 18 months.

What does it mean? 

The current service model (the way care is delivered) doesn’t meet the requirements of a modern service, with too much variation. The Government should produce a set of national standards to deliver safe care and improve services and outcomes across the whole care pathway (including in routine planned care and unplanned emergency care).

Workforce models should ensure senior decision makers (obstetric consultants and anaesthetists) are available 24/7 in hospitals and they should ensure the right skill mix of midwives across the 24-hour period. 

Research funding should be targeted at issues which need more evidence to ensure a sound evidence base when implementing new policies and guidance. 

How has the Government responded: 

In response to this recommendation, the Government announced new national standards for maternity triage to ensure women are assessed quickly, listened to properly and given safe, timely care from the moment they arrive. 

The triage standards were published by NHS England in July 2026: (link).

The Government also announced a total of 1,000 temporary roles will be created to help newly qualified midwives join the NHS, backed by more than £10 million in Government funding. 

Sands response:

We are pleased that a new national specification for triage has been announced, and that insights from bereaved parents have supported this work. This is an important step in improving local triage services and tracking and evaluating progress. However, to ensure that these specifications are sustainably embedded into services across England, the Government must make sufficient and sustainable funding and resources available, including staffing with clear monitoring and evaluation to ensure it is working.

A new modern service framework could provide the catalyst for reform of how services are delivered, however on it's own it cannot deliver the system wide change required – including a change in culture, education, regulation. wide change required – including a change in culture, education, regulation. To be effective the Modern Service Framework must bring together all the standards and service expectations required for safe, equitable and relationally competent maternity and neonatal care. It must not become another source of competing guidance.

Any modern service framework must include interventions which will have the most impact. We welcome research funding being targeted at gaps in evidence, to ensure policies are reflecting what we know works. Women and birthing people using services must be aware of the care they are entitled to through the framework. The Government must also ensure monitoring and evaluation of new policies.

DHSC, NHSE, ICBs, NHS trusts, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) must treat racism, discrimination and inequality as a critical maternity safety issue – within 12 months, with work starting immediately.

What does it mean? 

Racism and discrimination must be treated as critical safety issues (issues which can present a risk to life) requiring urgent intervention.

Where inequalities are identified and if patterns emerge referred to the board and linked to measurable improvement action. Regulators should also consider this as part of their assessment. 

Trusts should collect, analyse and act on data to identify inequalities in access, experience, safety and outcomes to target improvements. Whilst the categories in health datasets should be reviewed and reformed. 

How has the Government responded: 

The Government announced the national rollout of the Perinatal Equity and Anti-Discrimination Programme. 

Sands response:

We welcome the fact that that racism, discrimination and inequality are identified as the critical safety issues we know they are impacting on maternal and neonatal outcomes. 

The Government must now set out long-term, funded plans aimed at eliminating inequalities in pregnancy loss and baby deaths, including adopting targets to eliminate inequalities in stillbirth and neonatal deaths by ethnicity and deprivation. 

We know that there are inequalities in experience, for example during research for our Lost in the System mental health campaign we heard from LGBTQIA+ parents who were unable to access the mental health care they needed. The Government must improve data collection to ensure that we know whether inequalities are also present in outcomes. 

Research funding must be focused on developing effective interventions to address health inequalities and save babies’ lives. Currently, different interventions are being carried out by Trusts which have not been properly evaluated, driving variation and a lack of knowledge of which are most effective. Tackling inequalities will rely on whole system reform, including changes to education, impact reporting and Boards monitoring effectiveness. 

This will require cross-Governmental commitment to eliminating inequalities, backed by ringfenced, long term funding. 

DHSC/NHSE must clarify existing system governance, oversight and accountability structures and improve the effectiveness of regulatory oversight within nine months.

What does it mean? 

Regulators should work together to clarify responsibilities, remove duplication and improve effectiveness. 

The CQC should have a specialist unit to provide assessment for maternity and neonatal service, including clinicians from different professional backgrounds. 

Women and families should be at the centre, with regulatory methodology under regular review. 

How has the Government responded: 

The Government has not yet responded. 

Sands response:

Families must have confidence that regulators are ensuring the safety of services and that they are acting on poor care. However, bereaved families have consistently raised concerns about their care with regulators to no avail.  

In some cases, despite families raising concerns, and inspections finding safety to be inadequate or requires improvement, services are still rated as ‘good’. This erodes confidence in the regulators. The recommendations throughout suggest additional assessments the CQC should undertake – including looking at the quality of reviews and considering the escalation of critical safety issues to Boards and their response. 

Whilst the recommendations acknowledge regulation needs to be improved it does not go as far as suggesting a complete reform of the regulatory system. Complete reform is required as part of the reform of the review, complaints and investigation system. 

The Maternity and Neonatal Taskforce will also need to consider what legislative changes may be required to grant additional powers to regulators to take robust action against Trusts who fail to deliver safe care as well as who has oversight of the regulators. This should include considering who is regulating non-clinical managers and leaders, families experiences of regulators and how automatic regulatory referrals are made following complaints, reviews and investigations.  

DHSC, NHSE, ICBs and NHS trusts must work with colleges, universities, post graduate educators and others to improve culture and teamworking, and strengthen leadership at all levels of the system and across professions within 12 months.

What does it mean? 

Poor and unacceptable behaviour should be treated as a critical safety issue (a risk to life). 

Where poor behaviour is reported this should be collected as safety intelligence to enable escalation to Board when patterns emerge, linked to a measurable improvement action plan. It should also be considered by regulators as part of assessments.

Education and training for clinicians, should place trauma-informed care, bereavement care, compassionate care, communication, teamworking and response to adverse events at its core. 

How has the Government responded: 

The Government has not responded to this recommendation. However, the ten-point plan released by NHS England following the report sets out that bereaved families must receive bereavement care when specialist staff are not working.  

Sands response:

There must be a culture change in Trusts from ward to board, embracing a just culture which puts accountability, safety and justice at the centre. 

Whilst we welcome the emphasis on improving training, a change in culture must also extend to managers, leaders and the Board – staff who do not necessarily complete education or training programmes for clinicians. 

An organisation’s response when things go wrong, is often set by the legal and financial teams rather than maternity and neonatal teams. This results in the prioritisation of reputation management over justice or learning. This reiterates why a change in culture cannot be focused solely on clinicians.

We welcome that the recommendations include placing bereavement care and the response to adverse events at the core of education and training. However, this will require the Nursing and Midwifery Council to make this mandatory for midwifery programmes, and similarly across all other professions who may deliver care to families – including nurses, doctors and paramedics. NHS Trusts must ringfence training time for all healthcare professionals to complete training on an ongoing basis. 

However, completing a training course is not enough. The skills gained from training must be evaluated during education and in practice, they should be a core component of competency frameworks and professional accreditation. 

DHSC/NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, five-year and 10-year investment commitments and implementation deadlines.

What does it mean? 

Estates and physical environments are vital to safety. The report recommends standards for estates to be set out in the Modern Service Framework.

The report also recommends the rollout of digital maternity and neonatal systems across all providers. This will ensure one single digital record for mothers and baby’s which follows them. 

How has the Government responded: 

The Government announced a further £41 million to tackle urgent safety risks in maternity and neonatal facilities. This funding will address issues such as fire safety, ventilation issues and outdated infrastructure. 

Sands response:

It’s vital that standards for estates and physical environments includes ensuring appropriate bereavement spaces in all services where pregnancy or baby loss may occur, including A&E, gynaecology, early pregnancy and paediatric departments. As well as ensuring appropriate spaces, thought must be given to how these are accessed.

However, the Government’s response to provide an additional £41 million, on top of the already committed £145 since April 2025, is not enough to support every maternity unit in England. In 2025, there were 120 Trust with maternity services incorporating 155 obstetric units and a similar number midwifery led units. This will provide just over £1 million per obstetric unit for them to improve their complete estate. 

It can be extremely distressing and re-traumatising for families to have to repeat what has happened repeatedly, when healthcare professionals are unaware of a bereavement. This can continue for months or years after an experience of loss and into subsequent pregnancies. 

A singe digital record should ensure that all healthcare professionals have access to women, birthing people and baby’s history. There must be a standard process in place to flag pregnancy and baby loss on records, and staff must have the time they need to read notes thoroughly before providing care.