Systemic failures have been identified across NHS maternity services, highlighting many of the same root causes and contributory factors and calling for reform — particularly around listening to women, birthing people and their families, workforce, training, culture, governance and learning from harm.

Baroness Amos’ Final Report - National Maternity and Neonatal Investigation (NMNI) published on 30 June 2026 is a national, system-level review. The report makes recommendations which seek to create new statutory structures, reform regulation and redesign the whole service through a Modern Service Framework, the appointment of the UK’s first Maternity and Neonatal Commissioner and a National Maternity and Neonatal Taskforce.

The NMNI also addresses potential changes to the coronial system, the compensation and litigation framework, freebirth guidance, and regulatory reform. The overreaching aim is "to put in place a maternal and neonatal service with safety, quality, equity and compassion at its heart and crucially one in which women and families have a voice".

We recognise the scale of what is being asked. Absorbing and acting on these recommendations will take time - and rightly so. But the direction of travel is clear, and the expectation is that healthcare organisations begin now.

So where do you start? This article cuts through the detail of the NMNI to provide a check-list of key areas and immediate actions every healthcare organisation and professional involved in maternity services should be taking right now. For further information, our Shared Insights event will discuss how to implement change. 

Your immediate Board-level priorities

1. Listening to the voices of women, birthing people and families

NMNI recommendation: 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.

• Are you genuinely listening to, and learning from, families?
• Are you capturing patient voices as safety intelligence? Are you reviewing this at board level, linked to improvement actions?
• Does your Trust provide (or have a plan to provide) continuity of care for all scheduled antenatal and postnatal care with a postnatal debrief discussion to be offered to every woman and birthing person, by a midwife or appropriately trained clinician?

Trusts need to embed 'Listening to Women' as a Board-Level priority Patient Safety Requirement. 

Trusts must treat listening to women, birthing people and families as a critical safety issue and link findings to measurable improvement actions. This is a structural and cultural shift which requires a redesign of antenatal education and trauma-informed principles as routine practice.

2. Investigations

NMNI recommendation: 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.

• Does your Board and leadership have sufficient visibility of - and curiosity about - maternity safety?
• Are your investigation processes credible, transparent and family-centred? Is learning being embedded into practice?
• Are you complying with your Duty of Candour obligations when things go wrong?
• Are your mortuary governance records in order? For all Trusts that have a mortuary or routinely care for people after death, NHS England has asked for a Board Assurance Statement to be completed and returned by 31 July 2026.

Within 12 months, Trusts must:

• Improve the quality, transparency and accountability of their investigations. 
• Provide clearer communication to families about investigation pathways and timelines.
• Ensure specialist investigator training.
• Embed systematic sharing of learning, and robust oversight of the implementation of investigation recommendations. 

Under PSIRF, Trust leaders are directly accountable for ensuring investigations are credible, findings are acted upon, safety actions are implemented and monitored, families are meaningfully engaged and involved, and organisational learning leads to measurable improvement. 

3. Leadership, workforce and triage

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

NMNI recommendation:  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.

• Do you have parity of midwifery, obstetric and neonatal leads? 
• Are your teams using different growth charts for measuring fetal growth?
• Whilst national workforce model reviews are under way, are you complying with existing RCOG guidance on consultant/senior presence in and out of hours whilst national models are developed (Roles and responsibilities of the consultant workforce report (May 2022 update))?
• Is the Chief Medical Officer consistently engaged at board level on maternity and neonatal safety?

Trusts should ensure that a senior obstetric clinical lead is working alongside the Director of Midwifery in each provider, with consistent engagement by the Trust on maternity and neonatal issues alongside the Chief Nurse at board level. 

Triage is the report's most urgent call to action for individual Trusts and healthcare organisations and is a setting where time-sensitive clinical decisions are made and where delays or inappropriate decisions can have serious and irreversible consequences:

• Have you completed or commissioned a board-level triage audit? Is there a plan to report results to regions and to DHSC and NHS England within three months?
• Does your organisation have a dedicated midwife resource structurally independent of labour ward midwifery numbers to answer calls and provide timely advice, including an offer of face-to-face assessment if concerns remain after a telephone consultation?
• Is there psychological support in place for your staff?
• Do you have training in place for trauma-informed care, bereavement care, compassionate care, communication, teamworking and response to adverse events?

4.  Inequality, culture and behaviour

NMNI recommendation: 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.

• Are you treating bullying, poor and unacceptable behaviour, racism and discrimination as critical safety issues, appropriately governed and escalated to board level? 
• Are you collecting and acting on data about outcomes for women from Black and Asian backgrounds and those from deprived communities as safety intelligence, reviewed through patient safety governance? 
• Are you presenting this at Board-Level with linked improvement plans? 
• Is your culture one of psychological safety with staff able to raise concerns – do you have approachable leadership and teamworking across professions and from ward to board?

5. Estates and digital improvement

NMNI recommendation: 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. 

• Do you know what the forthcoming national standards will require of you?

The NMNI calls for:

• Enforceable estates standards.
• Revision of outdated Health Building Notes (within 12 months).
• Engagement with capital planning processes.
• A national timeline for interoperable digital maternity and neonatal systems (with the goal of every woman and baby having a single digital record).

Health organisations should assess the adequacy of their current estates and digital systems against the standards that will be set.

The future for maternity and neonatal care

Health Secretary James Murray states that over the next two weeks he will meet with a national task force (which Chair of the Health and Social Care Select Committee Layla Moran will sit on) "as quickly as possible".

Baroness Amos acknowledges that work is underway:

"There is already significant work going on in some of the areas we identify as needing attention. Where possible, we have identified how to build on existing work so as not to ‘reinvent the wheel’. The findings and recommendations set out a clear direction for change, focused on improving outcomes and experiences for women, birthing people and their families … We look forward to seeing the timely implementation of these changes and the continued evolution of maternity and neonatal services to ensure they are of the highest quality, responsive, person-centred, seamless and fit for the future."

Further resources and support 

The NMNI demands action — and every maternity professional, in-house legal team, senior leader and clinician needs to know what that looks like in practice.

To help you cut through the complexity, we have assembled a panel of leading legal, clinical and patient voices for our next Shared Insights session, 'What the National Maternity and Neonatal Investigation means for you – and what to do next', taking place on 14 July 2026.

Chaired by Browne Jacobson’s Kelly Buckley, Partner, and Amelia Newbold, Risk Management Lead, our expert panel includes:

• Sarah Land – Co-Founder and CEO of the charity Peeps.
• Dr Denise Chaffer – CBE FRCN, former Director of Safety and Learning for NHS Resolution and Chair of the Independent Review of Maternity and Neonatal Service at Swansea Bay.
• Ms Jyoti Sidhu – Consultant Obstetrician and Gynaecologist at Royal Berkshire NHS Foundation Trust.
• Lorraine Cardill – Director of Midwifery and Neonatal Services at George Eliot Hospital NHS Trust and South Warwickshire University NHS Foundation Trust.

If you are a healthcare provider or organisation looking for support, our specialist maternity team is here to help you organise, deliver and evidence safe, equitable and compassionate maternity care. Please contact our specialist maternity division lead, Kelly Buckley. We also offer tailored support to help NHS Trusts participating in the national investigation.

Looking for more guidance? Explore our Maternity Services Resource Hub.