Key Summary
- Baroness Amos’s investigation showed that the system is fragmented, overly complex and too slow to learn, and there is a lack of accountability when things go wrong.
- The new commissioner will provide independent leadership to hold the system to account, drive change and rebuild trust.
- The government would publish a comprehensive national action plan in December 2026, setting out priority actions and long-term reform to deliver safer, fairer care.
The government has decided to create the UK’s first-ever maternity and neonatal commissioner, as it looks to overhaul the country's maternity and neonatal care systems in the wake of Baroness Amos’s independent investigation.
The report stated that the system is fragmented, overly complex and too slow to learn, and there is a lack of accountability and answers when things go wrong.
Racism and discrimination are driving inequalities in care, and women and families are not being listened to, it added.
Baroness Amos examined the experiences of thousands of women, their families and staff, alongside local investigations of 12 trusts.
The new commissioner will provide independent leadership to hold the system to account, drive change and rebuild trust, and ensure that the voices of women are always heard.
The government would publish a comprehensive national action plan 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.
It will also invest an additional £41 million to tackle urgent safety risks in maternity and neonatal facilities, building on £145 million already committed since April 2025.
This funding will be used to create safer environments for mothers and newborns by addressing issues such as fire safety, poor ventilation and outdated infrastructure.
The government aims to end the postcode lottery and ensure every family receives the same high standard of care.
It will also roll out the Perinatal Equity and Anti-Discrimination Programme to address 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 task force will also be looking at all parts of the health system when things go wrong - including regulators - to ensure that accountability is established.
The government had earlier extended 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's or mother’s condition is deteriorating and they are concerned this is not being responded to.
Health secretary 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."
England's chief midwifery officer Kate Brintworth 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."
