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National Maternity and Neonatal Investigation
30 June 2026
Lead MP
James Murray
Debate Type
Ministerial Statement
Tags
NHS
Other Contributors: 35
At a Glance
James Murray raised concerns about national maternity and neonatal investigation in the House of Commons. A government minister responded. Other MPs also contributed.
How the Debate Unfolded
MPs spoke in turn to share their views and ask questions. Here's what each person said:
Government Statement
Less than a week ago, James Murray announced the results of Baroness Amos's investigation into maternity and neonatal services. The report highlights systemic failures over more than a decade in multiple locations across the UK, impacting thousands of families who have experienced inadequate care during pregnancy, labour, delivery, and postnatal periods. Despite numerous reviews and reports, changes have been insufficient, leading to ongoing issues with accountability and implementation of recommendations. To address these failings, Murray announced immediate measures including the appointment of a statutory maternity and neonatal commissioner responsible for driving change across NHS trusts; rolling out Martha’s rule to ensure women can demand second opinions; publishing new national standards for maternity triage; expanding perinatal equity and antidiscrimination programmes; investing £41 million in upgrading facilities; increasing midwifery staffing; and focusing on cultural changes within the healthcare system. The aim is to deliver safe, consistent care across the country by creating a comprehensive action plan by year-end.
Stuart Andrew
Con
Pudsey
Question
When will Leeds and Sussex reviews produce their reports, and how will Ministers act on concerns before they conclude?
Minister reply
The minister did not provide a specific timeline for the completion of the Leeds and Sussex reviews but committed to acting promptly on any identified issues as soon as they are available.
Stuart Andrew
Con
Pudsey
Question
Will the new triage standards be mandatory, and by when must every trust meet them?
Minister reply
The minister confirmed that the new national standards for maternity triage will be published this week and trusts are expected to implement these immediately.
Stuart Andrew
Con
Pudsey
Question
Will the estates funding include accommodation for parents close to neonatal units?
Minister reply
The minister did not provide a definitive commitment but acknowledged the importance of family accommodation near neonatal units and committed to reviewing this aspect.
Stuart Andrew
Con
Pudsey
Question
What are the powers of the statutory maternity and neonatal commissioner?
Minister reply
The minister stated that further details on the role's purpose, powers, and accountability will be clarified in due course but emphasised its importance in driving systemic change.
Stuart Andrew
Con
Pudsey
Question
I thank the Secretary of State for advance sight of his statement, and I thank Baroness Amos and her team for their compassionate work. As I said last week, I pay tribute to the women and families who gave evidence and to the babies at the heart of the inquiry. Many revisited the most painful moments of their lives after years of fighting to be heard. Their courage places a responsibility on us all... [Long question] ...Stuart Andrew closes by saying that both the Government and Opposition have a duty to support changes.
Minister reply
I thank the shadow Secretary of State for his tone and approach, appreciating the shared responsibility in this House. The minister discusses future investigations in Leeds and Sussex and ensures families will be included in the process. He mentions rolling out new triage standards immediately, ensuring that critical safety measures are incorporated into the action plan. The commissioner's role is described as crucial but not alone, serving as a voice for women. Temporary midwifery roles are an immediate step to ensure newly qualified midwives contribute and will be baselined in future years. New triage standards aim to identify issues early and provide support quickly to avoid extra harm.
Wes Streeting
Lab
Ilford North
Question
May I add my thanks to Baroness Amos? I emphasise the importance of culture change, but it will not happen without accountability. In all conversations with families suffering bereavement or harm, the cover-up culture in the NHS was shocking and persists to this day. There is a debate on place-based inquiries vs national statutory public inquiry, but whatever the outcome, any report must be worth the paper it's written on if all decision makers are held accountable through a duty of candour. Given that, where is the Hillsborough law? Will it at least go through before the summer recess?
Minister reply
I thank my right hon. Friend for his comments and agree about the importance of accountability in culture change. Without accountability, we will not have culture change across maternity services and senior clinicians will continue to avoid scrutiny when investigations take place. The duty of candour is the single most powerful change we can make because it sends a message to senior clinicians that they will be held accountable and face up to two years in prison if they refuse to co-operate. I agree on the importance of ensuring that the Hillsborough law gets on the statute book so that this duty of candour can apply to future maternity investigations.
Question
May I also add my thanks? The Amos report confirms our worst fears—maternity services in England are fundamentally broken with rising maternal mortality rates. We need genuine accountability through the NHS and Department of Health, accompanied by investment to make Britain the safest country for childbirth. I welcome the Government’s commitment to a national maternity commissioner but it cannot fix the broken system alone. Will the Government commit to implementing all recommendations from Baroness Amos's report and working with us to deliver the change needed?
Minister reply
I thank the hon. Lady for her comments and agree that the report confirms our worst fears. The taskforce I chair will take all national recommendations from Baroness Amos’s report, as well as Donna Ockenden’s report last week, and ensure that the action plan comprehensively addresses all issues raised. We need a comprehensive plan to truly transform the service.
Diane Abbott
Lab
Hackney North and Stoke Newington
Question
The Secretary of State will know that many women are never more vulnerable than in childbirth, particularly black women who suffer disproportionately. Black babies are still over twice as likely to be stillborn compared to white babies and black women almost three times more likely to die during pregnancy or shortly after birth. The whole House wants progress but it is not enough to have another inquiry; what black women want is equity of treatment and fewer deaths.
Minister reply
I thank my right hon. Friend for her comments and agree about the shocking failures in maternity services, particularly for black women who are at more risk than white women due to inequalities exposed by these failings. We will ensure that the perinatal equity and anti-discrimination programme is extended to all trusts by the end of next year, but this is just an immediate measure rather than the sum of all measures we will take on this front.
Jeremy Hunt
Con
South West Surrey
Question
I agree with the need for getting the culture right with accountability. When I was Secretary of State, we passed the duty of candour regulations to make it a criminal offence for trusts not to tell the truth to families when tragedy happens. Yet today, trust lawyers advise doctors not to be open about what happened due to legal action fears. Does the Secretary of State agree that we need to clear up this anomaly in the Hillsborough law so that it is just not possible for trusts not to tell the truth and trust lawyers always advise their own doctors, nurses and midwives that they must tell families exactly what happened?
Minister reply
I thank the right hon. Gentleman for his comments and agree on the importance of accountability for changing culture. We will look into this anomaly as part of our work to ensure that the system works properly. The expectation with the duty of candour, which will come in under the Hillsborough law, is to ensure that we never again have a situation where senior clinicians refuse to take part and cover up issues.
Question
Welcomes the report and asks for meaningful targets to reduce stillbirths and neonatal deaths, and introduce a target to eliminate inequalities in baby loss.
Minister reply
Acknowledges the importance of accountability mechanisms for monitoring implementation. Will ensure the national action plan has metrics and structures to make sure actions are implemented.
Layla Moran
Lib Dem
Oxford West and Abingdon
Question
Raises concerns about the commissioner's role being too much for one person, asks for commitment that Secretary of State will seek permission from Mr Speaker to make a statement once a year.
Minister reply
Emphasises that accountability includes the Secretary of State and Prime Minister. The commissioner’s role is to support Government work on implementing the national action plan.
Question
Highlights concerns about black and minority ethnic women still being dismissed and silenced, asks when real action will be published.
Minister reply
The action plan will publish by the end of the year. Highlights importance of midwives doing an important job and working hard to care for women.
Question
Raises concern about blood clots being No. 1 cause of maternal deaths, asks if Health Secretary will meet her.
Minister reply
Agrees the issue is important and offers to meet with Alicia Kearns to discuss it.
Question
Calls for measures to address disparity in treatment for black and ethnic minority women, asks for proper training and continuing professional development.
Minister reply
Acknowledges the importance of addressing discrimination and inequality. The anti-discrimination programme will be rolled out over a year and a half.
Andrew George
Lib Dem
St Ives
Question
Asks for mandatory safe frontline staffing levels for maternity services.
Minister reply
Acknowledges the importance of ensuring the right levels of staff and training. The taskforce will consider these issues in developing the national action plan.
Question
Asks if workforce challenges and impact on care are being addressed.
Minister reply
Acknowledges staffing is critical, taskforce will ensure right levels of staffing and responsibilities to prevent burnout or high workloads.
Julian Lewis
Con
New Forest East
Question
Last Wednesday, and again today, the Secretary of State expressed his shock at the number of senior clinicians who refused to take part in the Nottingham review. May I repeat a suggestion that I made last Wednesday? Those clinicians should be named publicly. That is a step that he could take straight away.
Minister reply
I will take away the right hon. Gentleman’s suggestion and think on it, because it is critical that we have accountability.
Question
We see the same problems again and again: misogyny, racism and a lack of accountability. I am therefore delighted that this plan will be developed in six months, through the taskforce, and that we will have a maternity commissioner. However, like me, I think she will have a question about timing.
Minister reply
We need to get the commissioner on a statutory basis as quickly as possible. Work on developing the plan and on establishing the commissioner will begin immediately.
Rosie Duffield
Lab
Canterbury
Question
The Health Secretary has repeated the importance of listening to women—the mothers, midwives, and experts. Why does he think that we have not been listened to, and are often not even invited into the room? How will he work to demonstrably change that in his time in the Department?
Minister reply
We need to change the culture in maternity services where misogyny exists and women’s concerns are ignored. One of the first actions we can take is to have accountability through a duty of candour.
Question
This review confronts us with a very uncomfortable but real truth. The reality is that this inquiry and the Donna Ockenden inquiry did not come about because of a system, NHS England or a regulatory authority; it came about because families have to keep on speaking up.
Minister reply
Families have driven this work for accountability, justice and change. We as MPs and Government Ministers support them in their drive.
Bernard Jenkin
Con
Harwich and North Essex
Question
Will the Secretary of State keep an open mind as to whether it is right to abolish the Health Services Safety Investigations Body, which was specifically designed to provide for a duty of candour?
Minister reply
The Minister of State for Health, my hon. Friend the Member for Bristol South (Karin Smyth), who is taking the NHS modernisation Bill through Parliament, is leading on the changes that we are seeking to make around HSSIP and the Care Quality Commission.
Battersea
Question
This report lays bare the scale of racism and discrimination in maternity and neonatal care. Can the Secretary of State say a little bit more about how he intends to be held accountable in this place, and about how senior clinicians will be held accountable for their actions?
Minister reply
Ultimately, it is right that I as Secretary of State and all Government Ministers are held to account by Parliament for our actions. The national action plan will explain exactly how we will embed accountability for racism and discrimination throughout the system.
Question
Recommendation 3 of the report calls for improvements to how the system responds when something goes wrong, including providing a sincere apology. Will the Secretary of State apologise now to my constituents Charlotte and James, who lost their baby Norah at Winchester hospital?
Minister reply
I am incredibly sorry to hear about her constituents Charlotte and James and their baby Norah. The responsibility to do something about it weighs heavily on all of us.
Question
I welcome the Secretary of State’s statement and the work of Baroness Amos on this vital report. Disabled women are 44% more likely to suffer a stillbirth than non-disabled women. Drawing on the evidence session I chaired with our MaternAble campaign of disabled mothers, Baroness Amos’s report highlights the devastating discrimination and structural barriers that are causing such inequalities for disabled women, from devastating assumptions that we are not sexually active or capable of parenting to the lack of accessible maternity spaces and medical equipment, as well as insufficient access to British Sign Language interpreters. It sets out the appalling lack of co-ordination and continuity of care across maternity pathways and services for disabled mothers. Will the Secretary of State meet me to ensure that disabled women’s voices are central to the Government’s taskforce and in implementing the report’s recommendations to overcome the inequalities we face in our maternity care?
Minister reply
My hon. Friend is an incredibly powerful advocate on the issue of the discrimination that disabled mothers face in the health service, but particularly in maternity services. She has spoken about both the discrimination and the barriers to accessing care; she is right to say that those barriers are wide and systemic, and that needs to be addressed as part of the comprehensive action plan. I would be very happy for myself or a member of my ministerial team to meet my hon. Friend to discuss this issue in more detail.
Question
I welcome Baroness Amos’s investigation, which has shone a light on the fact that these failings in maternity services are not isolated to one hospital or another, but exist across the piece. The Secretary of State rightly identifies that culture is at the centre of this issue, and that we must listen to the voices of women and of whistleblowers. That applies not just to maternity services, but across the NHS and, indeed, in public life more widely. The Secretary of State has spoken about accountability starting from the top, but I noticed that he swerved the question about whether he would come back to the House to report on progress against the goals he has set himself. It is shocking and shameful that black women are three times more likely than white women to die in maternity. Will he commit to coming back to the Chamber, reporting and holding himself to account on changing those racial disparities and ensuring true equity in healthcare?
Minister reply
I absolutely agree with the hon. Lady that I, as Secretary of State, must be held to account, and that is the role of this House. I will take that away and work out the best way of making sure that that happens, on a basis and to a timetable that people can understand, because I would like to make sure that I am held to account for delivering the whole action plan in the right way. I will take that point away and come back to the hon. Lady with an update.
Question
I, too, put on the record my thanks to Baroness Amos and her team, and to the families who relived their pain so that this report could exist—they are the real heroes here. I welcome the report, as well as the announcement of the new maternity and neonatal commissioner. It is vital that the report recognised structural racism, but that will mean nothing unless it leads to national standards that tackle inequality and deliver high-quality care for every mother and their baby. I note that the report stops short of recommending a target to bring racial disparities in maternity care to an end. Perhaps that is because the commitment was ours to keep from our manifesto. In April, the Minister for Secondary Care told the House that the target to end racial disparities in maternity outcomes would be informed by this report’s recommendations. They have been published now, so will the Secretary of State finally give us a timetable for delivering on that target? I remind him that black women are three times more likely to die in pregnancy and childbirth, and their babies are twice as likely to be stillborn. These are not statistics; they are mothers and children who are still dying. We promised a target at the last election. Without one, we cannot measure progress, and we cannot end that disparity.
Minister reply
My hon. Friend is right to draw attention to the disparity in what black women and their babies experience in the health service and the extra risks they face, particularly in maternity services. The taskforce will produce a comprehensive action plan by the end of the year, and I anticipate that it will include metrics for delivery and ways of monitoring progress. I will make sure that my hon. Friend’s comments are fed into the work of the taskforce.
Question
To deliver on this review’s recommendations in full will require serious capital investment. Just last week, we heard that St Helier, the hospital in my constituency, was considering closing its maternity unit altogether due to potentially unsafe pipework. Will the Government commit to reviewing the phasing of the new hospital programme, or at the very least providing the funds required to keep those buildings safe and open until the delivery of a new building?
Minister reply
On capital investment, I set out in my statement that we have announced an extra £41 million specifically to address critical safety issues in maternity and neonatal services. That funding is on top of the funding already in place, and it will help address those critical safety issues. The wider action plan will set out our overall approach. While funding will be a consideration in what the Government do, I again draw attention to the importance of deep-rooted issues such as culture, which must be addressed as part of the plan.
Question
I start by commending my right hon. Friend on his thoughtful and considerate approach to this investigation and other matters during his time in office. He rightly spoke about culture, and others have spoken about ideology. Does he agree that the only ideology that matters as we try to change this culture should be rooted in science and evidence? Will my right hon. Friend therefore consider ensuring that women in maternity are the first in line to be the beneficiaries of that science and evidence, whether through the single patient record or having access to their maternity care records? That data can make sure that poor care has nowhere to hide. We need to finally get AI-enabled scanners and replace the 19th-century equipment that is currently being used to listen to babies’ heartbeats. Finally, will my right hon. Friend share the findings of this report formally with the Scottish Government, because many of the findings on training, culture and clinical pathways will resonate there? Unfortunately, the Scottish Government have been less than forthcoming with their own investigations into this matter.
Minister reply
I thank my hon. Friend for his emphasis on the need to tackle the deep-rooted cultural problems in maternity services. He talks about how the only ideology that we should follow should be based on science and evidence. I agree with him on the importance of science and evidence, and of making sure that women are aware of the risks and benefits of the different options available to them, so that they can make informed choices. I add that the only ideology I would be comfortable signing up to is one that says that women must be listened to. That is a principle that I think we can all agree on, and we should make sure that it is embedded in our maternity services. My hon. Friend mentions investment in technology, including the single patient record. The single patient record can be of real benefit and make a difference, particularly in maternity services, and it will be enabled by the NHS modernisation Bill that is going through Parliament. I want to make sure that the single patient record is available to maternity services as quickly as possible. I am happy to share a copy of the report with the Scottish Government.
Question
The Secretary of State’s announcement of 1,000 extra midwives is welcome, even if the funding is temporary. However, this is a review of maternity and neonatal services. In Baroness Amos’s review of Sussex, she noted that in the 12 months ending in October 2025, only 50.1% of shifts at the Royal Sussex county hospital in Brighton were staffed according to British Association of Perinatal Medicine guidelines. What provision is the Secretary of State making to ensure that neonatal staffing is safe?
Minister reply
I thank the hon. Lady for welcoming the additional 1,000 positions to make sure that newly qualified midwives can find a way to contribute to the NHS. She raises staffing and training, as other Members have rightly done. The taskforce will consider questions about ensuring that we have the right staffing in place, with the right training to support it, ahead of the publication of the national action plan at the end of the year.
Question
This report is welcome, but that does not make its existence any less tragic. Far too many mothers and babies have been failed, including mothers like my constituent Amie, who late last year was turned away repeatedly, despite reporting reduced movements. Her baby Seren was born stillborn. The NHS spends almost as much on clinical negligence payouts as it does on maternity care itself. Can the Secretary of State update us on progress made following the Lock review into clinical negligence? It is about time we started investing in better care, rather than paying out for failure.
Minister reply
I was incredibly sorry to hear about my hon. Friend’s constituent Amie, who was turned away repeatedly from services despite asking for their help. We have heard that story far too many times as part of the work that Baroness Amos and Donna Ockenden have done and from our constituents. My hon. Friend is right to point out the amount of money that goes on clinical negligence, rather than making sure that services are better in the first place, which would avoid the need for clinical negligence payouts. I have met David Lock KC to discuss his ongoing work on that issue, and I will be working with him closely on it in the months ahead.
Question
Yeovil hospital was included as part of the review after the temporary closure of its unit last year. Since then, families, frontline staff and I have repeatedly raised concerns with Government and NHS leaders about working culture, bullying, staffing levels and support. Today’s review backs that up, after months of feeling that our concerns have not been properly acted on. Can the Secretary of State detail what the Government are doing to improve staffing levels in rural maternity units and to address working culture, leadership, accountability and whistleblowing?
Minister reply
The hon. Gentleman is right to draw attention to the impact that bullying and a poor working culture can have on maternity services. That focus on culture and on what we can do to change it will be a key part of the national action plan that the taskforce will develop. We want to make sure not only that staffing levels are correct and that staff have the right training, but that different members of staff work together across different disciplines and roles, because that is one way to make sure that the service improves.
Ian Byrne
Lab
Question
The Secretary of State, like countless other Ministers over the years, has stood at the Dispatch Box to outline and apologise for yet another state cover-up. Can we agree that enough is enough? Will he personally intervene and beg the Prime Minister to pass the Hillsborough law in full—it has been promised to us on numerous occasions—before summer recess and end this culture of cover-ups?
Minister reply
My hon. Friend is right to point to the importance of the Hillsborough law, because it will enable greater accountability and justice across society, as well as being crucial for future maternity investigations. That is why one of the commitments I made last week following Donna Ockenden’s report was to apply the duty of candour, which the Hillsborough law will enable, to all future maternity investigations.
Sarah Dyke
Lab
Question
A retired paediatrician and constituent told me recently that after giving 50 years’ service to the children of the NHS, she was devastated by the treatment of mothers and babies and loyal staff, whose concerns are routinely ignored, as when Yeovil’s specialist baby unit was recently closed without notice. While I welcome the Government’s commitment to a new maternity commissioner, will the Secretary of State set out how the commissioner will intervene in a trust like Somerset, rather than simply reporting on failures after harm has been caused?
Minister reply
In the coming two weeks, I will be meeting the national taskforce, which I chair, to establish the scope and role of the new national maternity commissioner. The hon. Lady also raised an important point about not only mothers being ignored, but staff being ignored. A few Members have made that point today, and it bears repeating.
Anneliese Dodds
Lab
Oxford East
Question
The lack of national maternity triage standards has been of huge concern to a number of my constituents, in some cases through bitter and heartbreaking experience. The Secretary of State said that NHS England would be responsible for rolling out and monitoring triage standards. Will that responsibility pass into his Department by April next year, and how will he ensure that those standards are genuinely implemented in every trust?
Minister reply
My right hon. Friend is right to point to the impact that national triage standards can make. The national triage standards are currently being set out by NHS England, which still exists. When NHS England becomes part of the Department for Health and Social Care, we will continue to monitor that, and the taskforce will also consider it as part of its national action plan.
Shadow Comment
Stuart Andrew
Shadow Comment
Stuart Andrew welcomed the immediate measures but expressed concern that families should not have to wait until the end of the year for broader changes. He highlighted that many women and babies continue to suffer due to failures in the system, urging the government to act on concerns raised before the Leeds and Sussex reviews conclude. The shadow minister called for clear commitments on triage standards implementation timelines, funding for parent accommodation near neonatal units, and details of the commissioner's role and powers. He also pressed for a timely publication of the 10-year workforce plan and ensured that all women receive early specialist care regardless of their risk factors. Andrew stressed the need to change cultural dynamics within maternity services to ensure that concerns are heard and acted upon.
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