National investigation into maternity and neonatal services

BRI Rainbow - Sunny Day

In August 2025 the Government announced that Baroness Valerie Amos had been appointed to lead the independent investigation into NHS maternity and neonatal services to drive urgent improvements to care and safety. The investigation will identify ways to urgently improve care and safety, with Baroness Valerie Amos working closely with bereaved and harmed families. It will also review the maternity and neonatal system, bringing together the findings of past reviews into one clear national set of actions to ensure every woman and baby receives safe, high-quality and compassionate care.

The National Maternity and Neonatal Investigation will develop one set of national recommendations to drive improvements in maternity and neonatal services across England.

It was announced on Monday 15 September 2025 that Bradford Teaching Hospitals NHS Foundation Trust is one of 14 trusts nationally that are included in the investigation.

Our services remain available, are safe and provided by passionate and compassionate health and care professionals.

Every year thousands of women give birth in our hospitals and community, and we want each and every one of those women to receive excellent care and have a positive experience with us. In the majority of cases this is happening, but not always and we know that isn’t good enough.

We are doing all we can to listen to the experiences of families using our services and the experiences of our colleagues, we welcome and encourage people to continue to share their feedback with us. And we are encouraging families that are using or have used our services, as well as our colleagues, to get involved in the national investigation should you want to share your experiences – including where your experience has been positive – so that all maternity and neonatal services across the country can learn from your feedback.

Compliments, concerns and complaints

Telephone: 01274 364810  |  Monday – Friday  |  9am – 4pm

Email: patient.experience@bthft.nhs.uk

The outcomes of our most recent inspections carried out by the Care Quality Commission (CQC) into our maternity and neonatal services are shared below.

Our most recent CQC inspections of maternity and neonatal services

Our maternity and neonatal services have been the subject of CQC inspections – all of which were unannounced – taking place, most recently in 2024.

CQC 2024 inspection of maternity services

The CQC undertook an unannounced visit in March 2024, and the service saw an improved rating of ‘Good’ in ‘Safe’ and remained ‘Good’ for ‘Well Led’. The service remained ‘Requires Improvement’ overall as the inspection did not cover the domains of ‘Effective’ and ‘Responsive’ which means that the overall rating is based on the 2019 full inspection, with ‘Caring’ rated ‘Good’ during that full inspection. You can read the inspection report on the CQC website.

CQC 2024 inspection of neonatal unit

The CQC report for Bradford Royal Infirmary’s Neonatal Unit in 2024 (published in November 2024, following an inspection in May 2024) with the service achieving an “Outstanding” overall rating. You can read the inspection report on the CQC website.

Questions and answers about the National Maternity and Neonatal Investigation

The questions and answers below have been shared by Baroness Valerie Amos to help local communities, colleagues and wider partners understand more about the investigation she is leading.

Why have these 14 trusts been selected for investigation?

The decision to review these 14 trusts is based on a range of factors. These include data and metrics designed to capture individual elements of a trust’s outcomes and its patients’ experiences – such as the CQC maternity patient survey and MBRRACE-UK perinatal mortality rates.

The final selection has also been made with a view to working to ensure a diverse mix of trusts, including:

  • Variation in case mix
  • Trust type
  • Geographic coverage
  • Provision of care to individuals from diverse backgrounds, including consideration of social, economic and racial inequalities
  • Family feedback
  • Where previous investigations have taken place.

By taking this approach the Investigation can capture experience and learning from a wide range of trusts, ensuring the findings are relevant across the system.

What is the scope of the investigation?

The aims of the investigation are:

  1. 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
  2. To 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.
  3. To 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.
How will the Investigation be conducted and how long will it take?

Local investigations will be carried out by trained investigators who will spend several days on site at each trust, supported by a small team. Our current expectation is that visits will take place between October and December 2025, though these timings are indicative only and may need to change.

We are aware of the pressures faced by all trusts during the winter months and are keen to be as flexible as possible in our approach, while meeting the ambitious timelines for this review. We are committed to providing at least two weeks’ notice for any information requests, as well as advance notice of site visits, to ensure the process is as manageable as possible.

Are individual staff members personally under investigation?

This investigation is about understanding and identifying lessons learned and driving the improvements needed to ensure high quality and safe maternity and neonatal care across England.

Will staff be expected to give evidence or speak to investigators?

The local investigations team will speak to some staff. They will be notified in advance if the team would like to hear from them as part of their work.

This investigation is about 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.

Will women and families be expected to give evidence or speak to investigators?

The local investigations will invite contributions from women and families who use the local services, but there will no obligation to contribute in this way. The national Investigation will also be conducting a public call for evidence so women and families who feel more comfortable contributing via this route will be able to do so.

Will representatives from the local Maternity and Neonatal Voice Partnerships and/or Local Maternity and Neonatal System have an opportunity to provide evidence or speak to the investigators?

The local investigations will invite contributions from all relevant parties when gathering evidence.