To:
- Trust chief executive officers
- Trust chairs
CC:
- Integrated care board chief executive officers
- Regional directors
23 June 2025
Dear colleagues,
Today, the Secretary of State for Health and Social Care has announced a rapid independent investigation into maternity and neonatal services. He has also announced an independent taskforce, alongside immediate actions to improve care.
This announcement comes on the back of significant failings in maternity services in parts of the NHS and we need – with real urgency – to understand and address the systemic issues behind why so many women, babies and families are experiencing unacceptable care.
It is clear that we are too frequently failing to consistently listen to women and their families when they raise concerns and too many families are being let down by the NHS. There remain really stark inequalities faced by Black and Asian women and women in deprived areas. In addition, we continue to have significant issues around safety and culture within our maternity workforce.
These have been persistent issues over recent years, so we now need to act with urgency to address these. The vast majority of births in England are safe and we have teams providing good and outstanding maternity and neonatal care every day. However, the variation in quality and performance across the NHS underscores why we can’t accept the status quo.
So, between now and December, the independent investigation will conduct urgent reviews of up to 10 trusts where there are specific issues. We’ll meet with relevant leaders of several organisations over the next month and while there will be some challenging conversations, we are really keen to hear what more we can be doing to support you to go further and faster in improving maternity and neonatal care.
In the meantime, we ask every local NHS board with responsibilities relating to maternity and neonatal care to:
- be rigorous in tackling poor behaviour where it exists; where there are examples of poor team cultures and behaviours these need addressing without delay
- listen directly to families that have experienced harm at the point when concerns are raised or identified; it is important we all create the conditions for staff to speak up, learn from mistakes, and at the same time staff who repeatedly demonstrate a lack of compassion or openness when things go wrong need to be robustly managed
- ensure you are setting the right culture: supporting, listening and working, through coproduction, with your maternity and neonatal voice partnership, and local women, and families
- review your approach to reviewing data on the quality of your maternity and neonatal services, closely monitoring outcomes and experience and delivering improvements to both
- retain a laser focus on tackling inequalities, discrimination and racism within your services, including tracking and addressing variation and putting in place key interventions; a new anti-discrimination programme from August will support our leadership teams to improve culture and practice
- this also means accelerating our collective plans to provide enhanced continuity of care in the most deprived neighbourhoods, providing additional support for the women that most need it
This is really challenging for all of us and the most important step we have to take to rebuild maternity and neonatal care is to recognise the scale of the problem we have and work together to fix it.
This will require us all to work together and this includes teams where care is outstanding where you will have a role to play in sharing best practice and supporting others to return their services to where their communities and staff want and need them to be. We hope you understand the importance of this and, as always, please get in touch if you want to discuss this ahead of the CEO call later in the week.
Sir Jim Mackey
Chief Executive Officer, NHS England
Duncan Burton
Chief Nursing Officer for England
Publication reference: PRN02043