Baroness Valerie Amos, chair of the national maternity and neonatal investigation in England, has today published her Interim Report.

The report shares the insights Baroness Amos has gained so far, which reflect what families, staff and others have shared and what the investigation team has seen. 

Baroness Amos has identified six factors which the investigation team have heard could be contributing to the pressures in the Maternity and Neonatal system. These are: 

1. Capacity pressures
2. Culture and leadership
3. Racism and discrimination
4. Poor responses and a lack of accountability when things go wrong
5. The quality of estates
6. Workforce 

Responding to the update, Sands Chief Executive Clea Harmer said: 

Devastatingly, but not surprisingly, the report has shared even more of the same real stories of parents who have experienced the issues and failures in care that Sands and other charities and groups have been highlighting and campaigning about with bereaved parents and families for many years. 

What’s really needed now is agreement on what better care looks like, and what targets and ambitions are needed to be able to track progress and ensure maternity services receive the appropriate attention, research funding, staffing levels and training to improve. 

As the investigation moves into its next stage, we urge Baroness Amos to consider the work already completed by the Sands and Tommy’s Joint Policy Unit that called for the government to set new ambitions for reducing perinatal mortality and preterm births – focused on matching the best-performing countries in Europe. 

And to eliminate inequalities in these outcomes based on ethnicity and deprivation, and to establish routine data collection on miscarriages.  

 

The Maternity and Neonatal Investigation in England have launched a call for evidence, a survey inviting people to share their experiences of care to help shape the future of maternity and neonatal services in England.

The survey will be open for 8 weeks, between 20 January and 17 March 2026.

We know that sharing experiences of care can be difficult, especially when you may have already done this before.

If you would like to take part in the survey, we have put together some information to guide you through this and help you decide if it is right for you:  National Maternity and Neonatal Investigation in England - Call for Evidence | Sands

Please remember that if any time you feel you no longer wish to take part in the call for evidence, it is ok to stop. We are always here to support you, so please do reach out: How we offer support | Sands. 

Baroness Amos has provided an update on the investigation, sharing that what she has seen so far "has been much worse" than she'd anticipated and nothing prepared her for "the scale of unacceptable care that women and families have received, and continue to receive."

The investigation team have met with over 170 individual families and visited several of the sites which are included in the local investigations. The issues which Baroness Amos has heard include: 

• Women not being listened to or given the right information to make informed choices at critical moments of their care as risk profiles change.
• 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.
• Fathers and non-birthing partners feeling unsupported.
• the impact of discrimination against women of colour, working class women, women with mental health challenges and younger parents leading to poorer outcomes.
• Lack of family engagement in reviews of care and feedback of review reports.
• The failure of regulatory bodies to protect vulnerable women and families and the perception of health professionals and organisations 'marking their own homework'.
• Women and families being placed in inappropriate spaces after loss or harm, for example, being put on wards with newborns after they have experienced a loss. 

These are issues which Sands and bereaved parents and families have been saying for years. Responding to the update, Sands Chief Executive Clea Harmer said: 

We were devastated by Baroness Amos' statement on the current state of affairs in maternity and neonatal care in England. It is deeply sad and frustrating to hear what Sands and bereaved parents and families have been saying for years. 

We know that listening to parents helps save lives. And we will continue to stand side-by-side with bereaved families and do all we can to make sure governments and NHS decision-makers hear their voices. 

However, it's clear that recommendations on their own change nothing. 

What is needed is wholesale systemic change, not tweaks to the current system. And this needs to be driven by determined leadership. Families deserve nothing less.  

 

Next steps: 

Baroness Amos has confirmed that: 

• A Call for Evidence for families will be launched in January 2026, and open for 8 weeks.
• A second update on the initial findings will be published in February 2026.
• The final report and recommendations will be published in Spring 2026. 

We will provide more information on the Call for Evidence when it launches. 

On 13 November, Madhuri Bedi, Sands Outreach Coordinator for South Asian Communities, attended a roundtable event on the maternity and neonatal experiences of South Asian women which will feed in to the Investigation. The barriers that prevent families from receiving the care they deserve was discussed, as well as the changes needed to create maternity and neonatal care that is safer, kinder, and more compassionate.

Madhuri shared findings from the Sands Listening Project where half of participants believed they received worse care or were treated differently by healthcare staff because of their ethnicity.

Madhuri was pleased to take part and said  "I hope that other voices will be added to the table to help amplify these important discussions for change and that together we can work towards equitable care for all. "