Skip to content
Seagry Consultancy
Menu
OverviewReviewsCommon purposeMethod

Reviews / 2026

Independent reviewPublishedMaternity and neonatalEngland

National Maternity and Neonatal Investigation

Baroness Valerie Amos · work from 2025 · published 2026

What this was

Rapid independent investigation ordered after the 10 Year Health Plan commitment and meetings with bereaved families. Baroness Amos was appointed in August 2025. The investigation looked at 12 trusts and at the national maternity system, and published final reports and recommendations on 30 June 2026. One expert adviser, Dr Bill Kirkup, stood down on 22 June 2026 because he could not agree the wording of the conclusions on normal-birth ideology.

Why it sits in the hub

It is the first national investigation that sits above the individual trust reviews. Thirlwall's report, published three months later, treated three of its recommendations — estates and digital systems, specialist maternity regulation, and investigation quality — as aligned with her own.

Findings

  1. Finding 1

    The investigation was set up because local reviews had not produced a national account of maternity and neonatal harm, or a single set of actions families could track.

    Learning from harmListening to patients and familiesMaternity and neonatal care

  2. Finding 2

    Inequalities in maternity outcomes were part of the remit, not a separate workstream.

    InequalitiesMaternity and neonatal care

Recommendations in this hub

Paraphrase of the public recommendations, not the official text.

  1. 1Awaiting responseDHSC and NHS England

    Deliver estates and digital systems that are fit for maternity and neonatal care, with dated investment commitments. Thirlwall recorded this as a recommendation of the Amos final report.

    Digital and informationEstates and the care environmentMaternity and neonatal care
  2. 2Awaiting responseNHS England, DHSC and CQC

    Create a specialist approach to regulating maternity and neonatal services, with clinicians involved, rather than a generic inspection model.

    Maternity and neonatal careRegulation and oversight
  3. 3Awaiting responseDHSC, NHS England and CQC

    Improve the quality and transparency of investigations, and show that learning is acted on.

    CandourLearning from harm
  4. 4Awaiting responseNHS England

    Reduce inequalities in maternity and neonatal care, and give families a route to accountability.

    The investigation's public description of its purpose. The full recommendation text is in the June 2026 reports.

    InequalitiesListening to patients and families