The 14 hospital trusts to be looked at as part of a rapid, independent, national investigation into maternity and neonatal services were named on 15 September 2025 by the Department of Health and Social Care (DHSC).
Baroness Valerie Amos’s investigation will put families at the heart of the work, the DHSC said, and affected families were asked to provide input to the draft terms of reference of the investigation. The terms of reference have been developed to focus on understanding the experiences of affected women and families, identifying lessons learned and driving the improvements needed to ensure high-quality and safe maternity and neonatal care across England.
The investigation was announced in June by Health and Social Care Secretary Wes Streeting after the government ‘inherited’ systemic problems in maternity and neonatal care dating back over 15 years. It comes alongside a package of immediate actions to improve care, including greater intervention by the Secretary of State and NHS chief executive to hold failing trusts to account: a key step in delivering the government’s mission to build an NHS fit for the future through the Plan for Change.
Secretary of State Wes Streeting said: “Bereaved families have shown extraordinary courage in coming forward to help inform this rapid national investigation alongside Baroness Amos. What they have experienced is devastating, and their strength will help protect other families from enduring what they have been through.
“I know that NHS maternity and neonatal workers want the best for these mothers and babies, and that the vast majority of births are safe and without incident, but I cannot turn a blind eye to failures in the system. Every single preventable tragedy is one too many. Harmed and bereaved families will be right at the heart of this investigation to ensure no one has to suffer like this again.”
The investigation will urgently look at a range of services across the entire maternity system, following independent reviews across numerous trusts that have revealed a pattern of similar failings: women’s voices ignored, safety concerns overlooked and poor leadership creating toxic cultures.
The Health and Social Care Secretary and Baroness Amos have agreed the terms of reference of the independent investigation, which will include understanding the lived experiences of families, reviewing the quality and safety of services, identifying the drivers and impact of inequalities, and identifying barriers to making improvements.
Following its conclusion, she will deliver one clear set of national recommendations to achieve consistently high-quality, safe maternity and neonatal care, with interim recommendations delivered this December.
Baroness Amos commented: “It is vital that the voices of mothers and families are at the heart of this investigation from the very beginning. Their experiences – including those of fathers and non-birthing partners – will guide our work and shape the national recommendations we will publish. We will pay particular attention to the inequalities faced by Black and Asian women and by families from marginalised groups, whose voices have too often been overlooked.
“Our aims are to ensure the lived experiences of affected families are fully heard, to conduct and publish 14 local investigations of maternity and neonatal services, and to develop recommendations informed by these that will drive improvements across maternity and neonatal services nationwide.”
The 14 trusts announced have been chosen for investigation based on a range of factors. They include data and metrics such as the Care Quality Commission maternity patient survey and MBRRACE-UK perinatal mortality rates, as well as criteria to determine a diverse mix of trusts.
Three of the trusts chosen – Shrewsbury and Telford, East Kent Hospitals and University Hospitals of Morecambe Bay – have been the subject of previous investigations and learnings from those will be incorporated in the new investigation.
Kate Brintworth, Chief Midwifery Officer for England, said: “This independent investigation is a crucial step in driving meaningful change in maternity and neonatal care, and the diverse range of trusts selected – including where previous investigations have taken place to incorporate learnings – will provide valuable insight to help teams across the country improve care for women, babies and families.”
The investigation will run alongside a National Maternity and Neonatal Taskforce – set up and chaired by the Health and Social Care Secretary and made up of a panel of esteemed experts and families – to keep up momentum and deliver change.