Baroness Amos has today published the final report and recommendations of the Independent National Maternity and Neonatal Investigation.

Sands has called for a complete reform of the maternity and neonatal system and we are pleased to see Baroness Amos acknowledge this.

There is no excuse for avoidable harm and death. Understanding the cultural and system failures as well as the pressures impacting the system is vital. If we don't reform the system, efforts to change it will fail.

- Baroness Amos

Her report shows that the maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre, embed a focus on listening to women, and ensure anti-racist practice at every level.

The National Maternity and Neonatal Taskforce, chaired by the Secretary of State for Health and Social Care, will develop and oversee a new national action plan in response to Baroness Amos’s findings.

The publication of Baroness Amos’ report must be a watershed moment for maternity and neonatal care in England. The work she has done, taken together with the many individual reports into NHS trusts, provide vital and incontrovertible evidence about what has gone wrong for so many families and cost so many babies’ lives. 

Listening with belief and respect should be at the heart of the care given to families, regardless of who they are or what their background or ethnicity is. Giving parents and families person-centred care is something we can and should change from today, but we also should not shy away from the longer-term scale of change that is needed.

At Sands we understand why bereaved and harmed parents and families are angry and frustrated. We must never forget there is a human cost to all these reports and investigations.

To get to this point families have once again had to share their experiences of loss and harm and this can be incredibly painful and traumatic. But every day we hear from parents who want a different future, who don’t want other parents to go through this pain; they want a legacy for their babies that is change for the better.

England’s maternity system needs to be rebuilt and centred around women, birthing people and their families, so they are supported and cared for at all stages of their pregnancy journey. Pregnancy loss and baby deaths in the UK are not inevitable. We know that at least 1 in 5 stillbirths and neonatal deaths could have been prevented with better care, and we need a system that ensures every family receives the care that they need.

This report is a once in a generation opportunity. The Government’s Maternity and Neonatal Taskforce now has the chance to create lasting change. And this chance must not be wasted.

- Dr Clea Harmer, Chief Executive, Sands.

Key findings from Baroness Amos' report

Baroness Amos outlines several themes repeatedly heard from women, families and staff:

• Women are not being listened to, heard or believed, with serious consequences for safety and quality of care, resulting in avoidable harm, trauma and loss of confidence in themselves and in the system.
   
• Racism and discrimination are embedded throughout the maternity and neonatal system, with unacceptable impact on safety, equity and quality of care, and staff wellbeing.
   
• Service design and planning is slow to respond to safety and demand and is not equipped to meet the changing needs of women, babies and families - including the changing profile of women giving birth and the increase in medical interventions during births.
   
• The system is fragmented and care is inconsistent – antenatal, birth and labour, neonatal and postnatal services are not joined up.

Women, babies and families deserve maternity and neonatal care that is safe, compassionate and equitable wherever they live. Too often, this Investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong.

This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it.

These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability, and create a system that learns when harm occurs.

- Baroness Amos

Baroness Amos' eight recommendations for change

The report sets out eight recommendations to redesign the maternity and neonatal system and deliver fundamental change:

• The creation of a statutory national Maternity and Neonatal Commissioner to drive the urgent, systemwide change identified by the Investigation and provide leadership for a redesigned maternity and neonatal system, through the Health Bill currently before Parliament.
   
• Systematically listening to the voices of women and families.
   
• Improving how the system responds when something goes wrong, including providing a sincere apology and learning lessons.
   
• Creating a modern service framework which sets out national standards to consistently achieve high quality maternity and neonatal care.
   
• Tackling racism, discrimination and inequality.
   
• Improving system governance and accountability structures and regulatory oversight.
   
• Improving culture and teamworking, and strengthening leadership at all levels of the system and across professions.
   
• Delivering estates and digital systems that are fit for modern maternity and neonatal care.

The Government has responded to Baroness Amos' report

The Secretary of State for Health and Social Care James Murray has said that a comprehensive National Action Plan will be published in December 2026, setting out priority actions and long-term reform to deliver safer, fairer care. 

This will be driven by the Taskforce, bringing together families, clinicians and other experts with a clear focus on safety, equity and accountability.

Alongside structural reform, the government has said it is investing a further £41 million to tackle urgent safety risks in maternity and neonatal facilities, building on £145 million already committed since April 2025. This funding will address issues such as fire safety, ventilation issues and outdated infrastructure – creating safer environments for mothers and newborns.

For too long women, babies and families have been failed by a system that didn’t listen. Their stories are heartbreaking and demand action. 

I am grateful to Baroness Amos for her work on this landmark review, which is a turning point. Appointing the UK’s first ever Maternity and Neonatal Commissioner will drive lasting change and make sure women and families are never ignored again.

- Secretary of State for Health and Social Care, James Murray.

Further urgent changes include the national rollout of the Perinatal Equity and Anti-Discrimination Programme. This will tackle unacceptable inequalities in care and outcomes, particularly for Black and Asian women, those from deprived backgrounds and other marginalised groups.

We are proud and pleased to see that the Government is rolling out the Perinatal Equity and Anti-Discrimination Programme to tackle inequalities in care for Black, Asian, and other underserved communities.  

This is a big victory: for years, Sands has been campaigning in partnership with Black and Asian bereaved parents and families, and many other organisations, friends and allies working in maternity safety and the baby loss community.   

We are pleased to see national standards for triage in England, included in the Government’s immediate response to Baroness Amos’ report.  

Every woman and birthing person deserves the same standard of care, no matter who they are and where they live. And no-one should be put off asking questions or telling maternity staff about their concerns. Triage should mean everyone gets the right care at the right time, for them and their baby.

Sands research, with parents' voices at its heart, and recommendations, have already informed NHS England’s first national maternity triage specification which sets out what good maternity triage services look like. And this is due to be published soon.

The newly announced Maternity Commissioner, and the National Maternity and Neonatal Taskforce, must now drive the level of change that is needed. These immediate responses from government are a start, but the taskforce must keep Baroness Amos' message front of mind  "If we don't reform the system, efforts to change it will fail.". And use this moment to create the roadmap for a wholly redesigned system alongside immediate, focused changes.

- Dr Clea Harmer, Chief Executive, Sands.

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