Maternity and neonatal care

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.

DHSC and NHS England

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

NHS England, DHSC and CQC

Give women clear information and a real choice, including about labour, pain relief and interventions.

Maternity services

Standardise assessment of fetal growth, triage, maternal early-warning scores and the recognition of deterioration.

Trusts and royal colleges

Set standards for care after a baby dies.

Trusts

Fit in-cot cameras in every neonatal unit, with ring-fenced national funding and a roadmap by March 2027.

NHS England

Name a lead in each neonatal unit for regular mortality data, reporting to the board.

Hospital trusts

Establish a national maternity and neonatal investigation and a taskforce to produce an action plan with families.

DHSC

Monitor outcomes in a way that spots a failing maternity service early.

NHS England

Listen to women and families, and give them a route to senior review when they are worried.

Maternity services

Fund a workforce plan that matches the complexity of the women being cared for.

NHS England and trusts

Expand mental health services and improve maternity safety as named programmes.

NHS England

Offer continuity of carer so that a woman knows the midwife looking after her.

Maternity services

Make rapid, multi-professional learning from incidents routine.

Local maternity systems

Commission a national review of maternity services.

NHS England

Investigate deaths and serious harm with a standard that looks for system failure, not a narrative that protects the unit.

NHS trusts