Issued by: Department of Health and Social Care and NHS England

New commissioner and extra funding announced to make maternity and neonatal care safer, fairer and more consistent across England.

• First ever commissioner to speak up for women, babies and families

• National action plan will be published in December to overhaul services and drive long-term change

• Additional £41 million investment to improve safety at maternity and neonatal facilities

• New standards for maternity triage across the country will end the postcode lottery in care

Families across the country will see their maternity and neonatal care overhauled, as the government today (Tuesday 30 June) takes urgent steps in response to Baroness Amos’s landmark independent investigation - including the creation of the UK’s first ever maternity and neonatal commissioner.

The new commissioner will provide independent leadership to hold the system to account, drive change and rebuild trust, co-chairing the National Maternity and Neonatal Taskforce with the Secretary of State. Crucially, the commissioner will ensure the voices of women are always heard by those at the heart of the system.

Baroness Amos examined the experiences of thousands of women, their families and staff, alongside local investigations of 12 trusts, and her report paints a stark picture.

It found a system that is fragmented, overly complex and too slow to learn, that women and families are not being listened to, that there is a lack of accountability and answers when things go wrong, and that racism and discrimination are driving inequalities in care. Staff also reported feeling unheard.

The measures announced today will begin the process of turning that around.

A comprehensive national action plan will be published in December 2026, setting out priority actions and long-term reform to deliver safer, fairer care. This will be driven by the taskforce, bringing together families, clinicians and other experts with a clear focus on safety, equity and accountability.

Alongside structural reform, the government is investing a further £41 million to tackle urgent safety risks in maternity and neonatal facilities, building on £145 million already committed since April 2025. This funding will address issues such as fire safety, ventilation issues and outdated infrastructure - creating safer environments for mothers and newborns.

Secretary of State for Health and Social Care James Murray said:

"For too long, women, babies and families have been failed by a system that didn’t listen. Their stories are heartbreaking and demand action.

"I am grateful to Baroness Amos for her work on this landmark review, which is a turning point. Appointing the UK’s first ever maternity and neonatal commissioner will drive lasting change and make sure women and families are never ignored again."

For patients, the changes will mean more consistent, responsive care. New national standards for maternity triage will ensure women are assessed quickly, listened to properly and given safe, timely care from the moment they arrive. The aim is clear: to end the postcode lottery and ensure every family receives the same high standard of care.

Further urgent changes include the national rollout of the Perinatal Equity and Anti-Discrimination Programme. This will tackle unacceptable inequalities in care and outcomes, particularly for Black and Asian women, those from deprived backgrounds and other marginalised groups.

A total of 1,000 temporary roles will be created to help newly qualified midwives join the NHS, backed by more than £10 million in government funding. The jobs will be for graduates and will help prevent a third of student midwives from leaving the profession.

The taskforce will also be looking at all parts of the health system when things go wrong - including regulators - to ensure that accountability is established.

Kate Brintworth, Chief Midwifery Officer for England, said:

"Too many women, babies and families have been harmed, bereaved or badly let down by maternity care, and too often women and families who raised concerns were not listened to.

"This has to change. Women and families must be taken seriously when they say something is wrong, and staff must feel able to speak up when they are worried about safety.

"The NHS is determined to address this quickly and we will work with the new maternity and neonatal commissioner to achieve this. NHS leaders are also coming together today to set out how immediate actions can be taken across all maternity and neonatal services in England to improve safety and the support and care offered to women and families.

"I know recent reports will be deeply worrying for women and families, but please continue to speak to your midwife or maternity team if you have any concerns. They understand and want to make sure you have the care and support you need."

Michelle Welsh MP, Maternity Adviser, said:

"I am pleased that a maternity and neonatal commissioner role will be established, and I look forward to seeing a robust appointment process take place.

"I want to thank Baroness Amos for her hard and thorough work on this report, as well as those who have contributed to this effort - most importantly the families who have shared their experiences, alongside the organisations that have supported this work.

"It is now vital that we work together to deliver meaningful and lasting improvements in maternity care centred around safety and compassion."

Baroness Lawrence of Clarendon OBE, Chair of the Race Equality Engagement Group, said:

"The findings highlighted by Baroness Amos’s important report reveal the deeply entrenched racial inequalities that exist in maternity and neonatal services in England.

"Racism and discrimination have no place in our health service. The fact that women have received worse care due to their race or background is totally unacceptable and cannot continue. I look forward to the government’s urgent work to now deliver the manifesto commitment to set a target for tackling the maternal mortality gap.

"I would also like to place on record my thanks to Baroness Amos for leading this vital and timely report."

These announcements build on significant action the government has already taken to improve maternity and neonatal services. This includes:

• implementing a new programme to reduce the 2 leading causes of avoidable brain injury during labour

• delivering a package of initiatives and interventions to reduce stillbirths, neonatal brain injury, neonatal death and preterm birth

• completing the full rollout of a Perinatal Culture and Leadership Programme to develop a culture of safety, learning and support for leads from all maternity and neonatal units

• expanding maternal mental health services to support women who experience moderate to severe or complex mental health issues following birth trauma or perinatal loss

• extending the baby loss certificate scheme to include all historic losses

• rolling out guidance across the NHS to tackle the leading causes of maternal death including thrombosis, mental health, epilepsy and haemorrhage

• publishing a maternity and neonatal equalities dashboard to support NHS trusts and integrated care boards to identify and address health inequalities while promoting transparency by publishing information on outcomes

• extending Martha’s Rule to maternity and neonatal wards in England to ensure every parent can request a rapid review from an independent medical team if a baby or mother’s condition is deteriorating and they are concerned this is not being responded to

• ensuring past and present NHS staff can be compelled to provide evidence in the upcoming maternity reviews in Leeds and Sussex, once the Public Office (Accountability) Bill completes its passage through Parliament

• driving improvements in the regulation of mortuaries - including an audit of over a decade of records to strengthen accountability

Many families have positive experiences of maternity and neonatal care, but tragically there have been too many cases of avoidable harm and tragic loss. Baroness Amos’s investigation explored the reasons why this has continued and what must now change.

It is vital that women who are currently accessing maternity or neonatal care raise any concerns they may have about themselves or their baby with their midwife - they are there to support you.

Background information

Baroness Amos’s final report and recommendations are available on the final reports page of the National Maternity and Neonatal Investigation website: [https://www.matneoinv.org.uk/final-reports]

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