LSHTM expert analyses what report means for women, babies, and families and the challenge of delivering sustained improvements to care
On 30 June 2026 Baroness Amos published the final report and recommendations of the Independent National Maternity and Neonatal Investigation.
The report highlights areas of concern, identifies barriers to change and makes recommendations aimed at transforming maternity and neonatal care in England.
Cally Tann, Professor of Neonatal Medicine and Child Health at the London School of Hygiene & Tropical Medicine (LSHTM) and practicing NHS consultant in neonatal medicine, said:
"This report provides a comprehensive assessment of the systemic factors that continue to affect the safety, quality and equity of care for mothers and babies in England and sets out a clear programme of recommendations to support long-term improvement. Its conclusions reinforce that we need to strengthen leadership, organisational culture, workforce support, accountability, learn from adverse events, and forge meaningful partnership with families. This needs to be done while addressing the persistent inequalities, racism and discrimination that continue to affect experiences of care and outcomes for women, babies and families.
"The report rightly recognises that families must be central to improving maternity and neonatal care. Their experiences provide essential insight into where services succeed and where they fail, and they should continue to shape the design, delivery and evaluation of care. Achieving this requires more than consultation. Services need inclusive, well-supported mechanisms that enable families from all communities, including those whose voices are too often underrepresented, to contribute meaningfully to improvement, with barriers relating to language, culture, disability, trust and access actively addressed. Lasting improvement will depend on learning with families as equal partners, alongside clinicians, managers and researchers, to build systems that are responsive, transparent and continuously focused on improving safety, quality and equity.
"The recommendation to strengthen maternity triage is particularly important. For many women and birthing people, triage is the first point of contact when concerns arise during pregnancy and increasingly functions as the front door to urgent maternity care. Ensuring that these services are appropriately staffed, supported by robust clinical assessment processes, and that concerns raised by all those accessing these services are consistently listened to and acted upon will be critical to improving safety and preventing avoidable harm. Organisations must be given the time, leadership and resources needed to embed learning, evaluate progress and sustain improvement.
"Delivering change will require collective leadership from government, the NHS, professional bodies, researchers and families, together with continued investment in the workforce, education, service improvement and learning systems. Whilst I believe those providing frontline care remain committed to delivering the highest standards of care, they must be supported with the time, workforce capacity, training and the organisational cultures needed to translate these recommendations into improvements in everyday practice. This includes ensuring that all professionals have equitable access to high-quality, multidisciplinary training in the recognition and management of deteriorating maternal and newborn conditions, culturally safe and personalised care, and understanding and addressing the impact of racism, bias and discrimination on care.
"The recently launched NIHR Maternity Disparities Consortium has an important role to play in supporting this next phase of improvement. By bringing together researchers, clinicians, maternity and neonatal services, policymakers, community organisations and families, the Consortium is working to generate the evidence needed to reduce inequalities and ensure that improvements in care are implemented effectively and equitably. This includes co-producing solutions with women, birthing people and families, strengthening the evidence for what works to improve outcomes, and supporting the implementation and evaluation of interventions that can be adopted across the NHS. Lasting change will depend not only on identifying what needs to improve, but on understanding how to deliver and sustain those improvements in partnership with the communities they are intended to serve.
"Our thoughts remain with the parents and families whose experiences are at the heart of this investigation, recognising the extraordinary courage it has taken to share their experiences, often at considerable emotional cost, in the hope of preventing similar harm to others. Their contribution has been fundamental to this investigation, and we owe it to them now to ensure that the lessons identified are translated into meaningful and sustained improvements in care."
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