Independent Investigation into Maternity and Neonatal Services Interim Report: Proactive steps for NHS Trusts

03 March 2026

Kelly Buckley and Amelia Newbold

On 26 February 2026, Baroness Valerie Amos published the Interim Report of the Independent National Maternity and Neonatal Investigation (the ‘Interim Report’), building on the Reflections and Initial Impressions report, published in December 2025.

The Interim Report provides powerful insights from further engagement with women and families, community organisations and staff, making it clear to all that the system, nationally, is under extraordinary strain and that a step change, based on a family first, whole system approach is urgency required to ensure the provision of safe, consistent and equitable care.

The Interim Report sets out important context and identifies six key factors which could be contributing to the pressures on the maternity and neonatal system. However, the final report, with one set of national recommendations, is not expected until Spring 2026. The Secretary of State for Health and Social Care will then chair a National Maternity and Neonatal Taskforce whose role it will be to design and deliver an Action Plan informed by the report findings and its recommendations.

Next steps

NHS Trusts with maternity units will, of course, need to await the final recommendations and Action Plan to understand what changes will be required and the timescale for these to be implemented. However, we recognise that some NHS Trusts may wish to take pro-active steps now, to begin to address the issues which have been identified in the Interim Report and to be as well placed as possible to implement the recommendations and Action Plan once published.

We appreciate that every maternity unit will be different and that, as highlighted by the Interim Report, maternity and neonatal services are under exceptional pressure. We are also aware that considerable work is already being undertaken to improve the delivery of maternity and neonatal services. However, we hope this checklist of suggested steps is a helpful tool to guide your strategic planning ahead of the publication of the final report and Action Plan.

Proactive steps NHS Trusts with maternity units may wish to consider now:

Audit triage and day assessment service: Some units have already taken steps to address capacity pressures, including increasing the number of senior obstetricians and staff to answer families' phone calls and prioritise assessments. However, consider whether your unit has enough senior decision-making capacity available on a 24-hour basis.
Review duration of antenatal appointments: Antenatal appointments need to be long enough to discuss a woman’s pregnancy meaningfully – particularly for women with complex health needs. In particular, it is important to ensure women have access to information about material risks and reasonable alternative treatment options for informed consent and that staff have adequate time to document the detail of these discussions properly.
Review redeployment practices: Moving community midwives to delivery units compromises care in neighbourhood settings and disrupts continuity of care, with staff not always familiar with working practices in another area. Where the deployment of staff is sometime unavoidable, ensure robust induction and competency checks are in place.
Examine physical layout: When triage, theatres, postnatal wards and the neonatal unit are physically close together, this reduces waiting times for medical review and enables close teamworking. Even where structural change is not immediately possible, consider how care pathways can be reorganised to reduce unnecessary movement.
Review IT systems and record-keeping processes: Review how patient information is recorded and shared across teams to identify any information gaps and what interim measures be implemented to reduce the risks.

Invest in clinical leadership and protected time: Audit whether clinical directors and heads of midwifery have adequate time and resources for leadership, and whether they are sufficiently connected to the Board.
Review processes for managing conduct issues where poor behaviour is identified: Ensure that disciplinary processes are applied fairly and consistently and actioned promptly and with transparently.
Staff wellbeing: Consider what can be done to improve wellbeing support, recognition of good practice, and creating safe spaces for staff to speak openly.
Strengthen multidisciplinary teamworking: It is important for obstetricians and midwives to work effectively in teams, respecting each other's expertise and having a shared approach to common objectives. Review opportunities for regular joint training, simulation, and shared debriefing to build the mutual respect that good teamwork requires.
Consider implementing Family Integrated Care (FiCare) models: The Interim Report cites the positive impact of FiCare models which actively involve families in decision-making and in supporting their baby's care. Consider whether this is something that could be adopted in your unit.

Review local equality data: Every maternity unit should be monitoring outcomes by ethnicity and deprivation and should have a clear plan for addressing disparities identified.
Ensure a zero-tolerance approach to discrimination: It is essential to consider the extent to which racism and discrimination are present, tolerated or actively addressed. This includes racism directed at patients, racism between staff, and structural racism embedded in policies and practices.
Develop culturally competent care and challenge and eliminate harmful stereotyping: Train staff in culturally sensitive communication, and review whether your information and communications materials reflect the diversity of your local community.
Engage and partner with community organisations: Voluntary and community organisations play an important role in facilitating earlier engagement with services, sharing information, supporting navigation of services, and building confidence and trust. Consider reaching out to local community organisations and explore how you can support or strengthen those relationships - particularly for communities that currently have lower engagement with maternity services.
Ensure interpreting services are accessible and reliable: Persistent challenges include limited availability of interpreters for specific languages or dialects, unreliable remote interpreting technology, and interpreters of inappropriate gender for sensitive discussions. Consider auditing your provision and address gaps as a patient safety priority.

Focus on a culture of candour, not just your policy: Candour must be a cultural norm, not a compliance exercise. Ensure that staff are trained, supported, and held accountable in relation to their duty of candour obligations.
Involve families meaningfully in investigations: Review your PSIRF and other relevant investigation processes to ensure families are genuinely informed and included at every stage. Ensure appropriate oversight of investigations and learning responses to ensure quality.
Act on investigation findings and safety recommendations to close the loop on learning: Ensure there is a clear process for tracking the implementation of learning from incidents, with Board-level oversight and accountability.
Review bereavement care provision and consider whether out-of-hours access can be improved, even incrementally.
Ensure records are accessible where appropriately requested: Support families who wish to access records and ensure compliance with subject access request obligations.
Provide clear, compassionate communication after harm: Empower staff to have compassionate conversations with families. This includes saying sorry meaningfully when things go wrong. NHS Resolution is clear that saying sorry is not an admission of liability and is always the right thing to do.

Conduct an estates review through a clinical safety lens: Identify where physical limitations are creating safety risks, for example, inadequate resuscitation space, poor co-location of services, insufficient bereavement facilities and escalate these to the Board with evidence.
Ensure adequate bereavement facilities: Trusts without adequate bereavement facilities should put interim arrangements in place while longer-term solutions are pursued.
Assess co-location of key services: Review whether clinical areas are optimally configured to support safe and efficient care.

Review staffing levels, skill mix, and supervision arrangements to ensure safe and equitable care: This includes reviewing any out-of-hours gaps, particularly in bereavement and specialist care.

How we can help

If you would like to discuss any aspect of the Independent Investigation into Maternity and Neonatal Services in England or how our specialist team can support you more generally, please contact Kelly Buckley, Partner and head of our specialist maternity division or our dedicated Risk Management Lead, Amelia Newbold, or visit our maternity services hub.