Guidance

National maternity and neonatal investigation: terms of reference

Published 15 September 2025

Applies to England

Aims

The aims of the investigation are to:

• develop and publish one set of national recommendations to:
  • drive the improvements needed to ensure high-quality and safe maternity and neonatal care across England
  • reduce inequalities and promote health equity in the delivery of those services
  • help bereaved and harmed families to receive justice and accountability in the future
• ensure that the lived experiences of women, babies and families, including fathers and non-birthing partners, are fully heard and used to inform the development of the national recommendations
• conduct and publish 14 local investigations of maternity and neonatal services in NHS trusts and use these alongside other sources of data and evidence gathered by the investigation to inform the development of the national recommendations

Scope

Understanding lived experience

The investigation will aim to understand the lived experiences of women, babies and families in England at all stages of the maternity and neonatal care pathway, hearing directly from those individuals.

This will include: 

• collating and learning from experiences recounted by families from previous national investigations, public inquiries and public calls for evidence
• learning from the experiences of women, babies and families who have been harmed during the delivery of maternity and neonatal care
• understanding the impact of adverse experiences on the physical, mental and emotional health of individual women and family members
• understanding the impact of adverse experiences on individuals and families including social and economic costs

Reviewing quality and safety of maternity and neonatal services

The investigation will review the quality and safety of maternity and neonatal services delivered to women, babies and families across England, identifying routes to reduce the incidence and severity of harm done to women, babies and families. This will have a particular focus on the experiences of women, babies and families as they engage with all stages of the maternity and neonatal care pathway. 

This will include: 

• undertaking local investigations into maternity and neonatal services in 14 NHS trusts
• understanding models of care delivery in maternity and neonatal services provided across England, including how care is provided for those with increased risks or with additional needs and with a focus on compassionate care delivery. This will include understanding variations in care delivery and compliance with national guidelines
• understanding the recognised risks present in all maternity and neonatal care and the system’s response to anticipating, identifying and managing these risks as they develop in individual cases
• understanding the way in which accountability is established for maternity and neonatal services across the healthcare system, and the impact this has on learning from mistakes. This will include consideration of how families are provided with clear and accurate information about what has happened
• identifying clinical and managerial accountability structures within NHS trusts and local healthcare systems across the maternity and neonatal services pathway and the accessibility of these structures to the public. This will include the role of regulatory bodies

Identifying drivers and impact of inequalities

The investigation will aim to identify the drivers and impact of inequalities faced by:

• women, babies and families from Black and Asian backgrounds
• those from deprived groups
• those from other marginalised groups when receiving maternity and neonatal care

This will include: 

• understanding drivers of adverse outcomes and poor experience for women, babies and families facing the worst inequalities, including:
  • racism
  • discrimination
  • lack of culturally sensitive care
  • language barriers
• understanding the impact of inequalities on outcomes and experiences for women, babies and families receiving maternity and neonatal care, including the way in which previous experiences can contribute to a reluctance to seek care
• identifying opportunities for reducing health inequalities and promoting health equity

Understanding the experiences of staff and healthcare professionals

The investigation will aim to understand the experiences of staff and healthcare professionals delivering care at all stages of the maternity and neonatal care pathway, and how they can best be supported in providing high-quality, safe and compassionate care. 

This will include: 

• understanding the experiences of staff and healthcare professionals, at local, regional and national levels, working in the maternity and neonatal care pathway
• understanding how organisational culture and leadership styles influence how staff and healthcare professionals deliver care across maternity and neonatal pathways
• identifying the extent to which recruitment, retention, education and training support staff as they deliver care across the maternity and neonatal pathway

Examining the response of healthcare organisations

The investigation will examine the response of local and national healthcare organisations to women, babies and families when things go wrong or harm occurs, including preventable deaths and harm, during the delivery of maternity and neonatal care. This will include reviewing how healthcare investigations are undertaken, including establishing accountability.

This will include:

• understanding leadership, governance and accountability structures at local, regional and national levels for maternity and neonatal services and assessing the extent to which these bodies work effectively together
• assessing the quality of the response of NHS trusts and integrated care boards (ICBs) when things go wrong or harm occurs, including investigating and learning from incidents and promoting honesty, transparency and candour. This will include the responses of local maternity and neonatal systems
• identifying and understanding how NHS trusts and ICBs demonstrate compassion in their response to women and families when things go wrong or harm occurs, including in the provision of bereavement care
• assessing the responses of NHS trusts and ICBs to whistleblowing from staff and complaints from women and families, including the role of lawyers and legal processes
• identifying how NHS trusts and ICBs learn from mistakes and if the learning is consistently applied
• understanding the way in which accountability is established and the impact this has on learning from mistakes. This will include consideration of how families are:
  • provided with clear and accurate information about what has happened
  • kept informed as reviews and investigations are conducted
  • given an opportunity to input
• understanding how the way in which record keeping and data sharing is undertaken affects families’ ability to access information during and after an investigation, including the issue of falsified or missing records
• understanding the impact of specific professional beliefs and approaches around birth, for example, the extent to which avoidable serious harm or deaths are normalised and become a ‘normal birth’ ideology or the normalisation of pain. This includes the role of educational institutions in endorsing these approaches
• understanding how learning and best practice is identified and adopted in institutions and organisations across England
• understanding the potential role of coroners in the investigation of late term stillbirths (37 weeks or later) and identify mistakes which would help prevent future deaths

Reviewing previous recommendations

The investigation will undertake a thematic review of previous recommendations that have been made by public inquiries and national investigations into maternity and neonatal care from 2015 to the present.

This will include: 

• identifying how many of those recommendations have been implemented
• understanding the impact of those recommendations that have been adopted and implemented
• identifying the reasons recommendations have not been implemented

Identifying opportunities and barriers to potential improvements

The investigation will aim to identify the opportunities for and barriers to making improvements and implementing previous recommendations in maternity and neonatal care, considering cultural and systematic factors. 

This will include: 

• understanding the barriers to addressing known risks in maternity and neonatal care and barriers to implementing previous recommendations, considering organisational culture, leadership and systematic factors
• identifying opportunities to improve maternity and neonatal care and facilitate adoption of high-impact recommendations
• considering the timeline for different recommendations, both short and long term

Assessing examples of good practice

The investigation will undertake an assessment of national and international examples of good practice in maternity and neonatal care and identify areas for further exploration.

This will include: 

• conducting an analysis of examples of best practice within the UK and in up to 3 comparable countries, considering quality and safety outcomes and patient experience
• identifying possible approaches from these national and international examples for improving quality, safety or patient experience for further exploration

Investigating revenue and capital investment

The investigation will hear from system leaders about the revenue and capital investment into maternity and neonatal services and opportunities for targeted or redirected investment for service improvements.

This will include: 

• understanding the impact of estates, equipment, finance and facilities on the delivery of high-quality and safe maternity and neonatal services
• identifying and prioritising opportunities for targeted investment in high-impact areas, considering impact in terms of:
  • quality
  • safety
  • inequalities
  • the experience of women and families
  • government policy
  • speed of delivery
• identifying areas of low value spend and opportunities to redirect investment to interventions better targeted at improving services

Methodology 

The detailed methodology for this independent investigation will be developed in collaboration with the independent chair and will be published in due course. This will:

• incorporate the views of affected families and their representatives
• include consideration of the way in which data requested from NHS trusts and other organisations will be used to inform the independent investigation

The investigation will collect evidence through a range of methods, including: 

• local investigations into maternity and neonatal services in 14 NHS trusts
• a call for evidence from the public
• evidence panels, including:
  • families
  • Black, Asian and other seldom heard communities and inequalities experts
  • academics and clinicians
  • healthcare professionals working in maternity and neonatal care
• a desktop review of all previous recommendations that have been made by public inquiries and national investigations into maternity and neonatal services and their impact
• a desktop review of national and international examples of good practice in maternity and neonatal services
• data requests from relevant local and national organisations

Sites for the local investigations 

The trusts to be reviewed are:

• Blackpool Teaching Hospitals NHS Foundation Trust
• Bradford Teaching Hospitals NHS Foundation Trust
• University Hospitals of Leicester NHS Trust
• Leeds Teaching Hospitals NHS Trust
• Sandwell and West Birmingham Hospitals NHS Trust
• Gloucestershire Hospitals NHS Foundation Trust
• Somerset NHS Foundation Trust
• Oxford University Hospitals NHS Foundation Trust
• University Hospitals Sussex NHS Foundation Trust
• Barking, Havering and Redbridge University Hospitals NHS Trust
• Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust

An additional 3 trusts have been selected for review because they have been subject to previous reviews or investigations. These are:

• University Hospitals of Morecambe Bay NHS Foundation Trust
• East Kent Hospitals NHS Foundation Trust
• Shrewsbury and Telford Hospital NHS Trust

Chair and expert advisors

The independent investigation will report to the independent chair, Baroness Valerie Amos. The chair will be supported by a small team of expert advisors.

The chair will engage regularly with affected families throughout the investigation process.

Investigation support team

The chair and expert advisors will be supported by the investigation support team. The independent investigation will have the full support of the Department of Health and Social Care (DHSC) and NHS England.

Reporting 

The investigation started work in summer 2025. Some initial findings will be published in December 2025 ahead of further findings in spring 2026.

Definitions 

The investigation has used the following definitions in preparing these terms of reference: 

• families - this investigation includes mothers, fathers, non-birthing partners and other family members and relatives involved with or affected by the birth of a child in the definition of family
• health inequalities - this investigation will consider health inequalities to be unfair and avoidable differences in health across the population, and between different groups within society
• all stages of the maternity and neonatal care pathway - this investigation will consider the maternity and neonatal care pathway to include:
  • pre-pregnancy advice and care
  • pregnancy care
  • labour
  • birth
  • neonatal care
  • postnatal care including psychological support
  • care and support including bereavement care for adverse outcomes such as miscarriage, stillbirth, perinatal, and maternal morbidity and mortality