The interim report, published by the Independent Investigation into Maternity and Neonatal Services in England, highlights systemic issues facing services. While this systemic focus is welcome, the final report must be solution-focused, including defining what ‘safe care’ looks like and how this can be delivered. 

The investigation will develop one set of national recommendations; it must consider  the necessary resources, identify responsible parties, and commit to effective evaluation.  The Taskforce should oversee progress against these recommendations and ensure delivery partners are held to account for timely implementation. 

 

Tackling variation in service delivery must go beyond a focus on capacity pressures, to ensure more babies  receive care that is in line with nationally agreed standards. Variation in care can be caused through lack of clarity over guidance, lack of resources and capacity, lack of oversight of adherence to guidance, and lack of guidance altogether. The investigation must consider the reasons for unwarranted variation and provide clear and simplified national guidance with sufficient flexibility, to allow for local population needs and improved dissemination. 

 

Culture and leadership must be improved at every level, to ensure better working relationships and effective leadership. While NHS England has implemented a perinatal culture and leadership programmes to solve these issues, external evaluation has found ‘limited evidence’ of change within services, and a failure to spread learning across the system.  It is vital that systems create a culture that encourages staff to share and escalate concerns, without fear of retribution.  

It is the responsibility of Trust boards to ensure the safety and quality of maternity and neonatal services, but there must be greater support to enable them to deliver this responsibility. Firstly, for frontline staff to improve the quality and consistency of reports shared with the board, and secondly for board members to properly interpret the information that they receive. 

 

Recognition of racism and discrimination is welcome, but action is needed to adequately capture the breadth of women and birthing people’s contexts, living circumstances, and identities which may affect pregnancy outcomes. Additional metrics must be agreed and integrated into NHS systems, and support must be given to staff to collect data sensitively. Improving data quality and collection can inform a comprehensive, cross government approach to tackling inequalities in pregnancy and baby loss. 

 

In the immediate term, pilot interventions to tackle racism and discrimination must be adequately funded and evaluated. Staff must be supported to deliver culturally competent, personalised care, to tackle racism and discrimination.  In the longer term, solutions must address the wider drivers of inequalities.  

Reviews of deaths must be reformed to centre bereaved families and embed learning, to prevent other babies dying in similar circumstances. The current system for reviews must be simplified and improved to enable parents to engage should they want to, and to reduce the current reliance on clinical notes. One suggestion is the creation of a single portal where parents can view all information and reports, as seen in Denmark. 

Learning must lead to improvements in service delivery by focusing on systemic issues, ensuring recommendations are informed, ringfencing staff time, ensuring boards take an active role, and enabling leadership at all levels to ensure accountability for implementation. 

Without oversight of implementation of actions, bereaved parents cannot be effectively updated nor can be assured that effective learning has taken place. 

 

Improving the quality of estates will support the delivery of safer care. Too many maternity units are currently not fit for purpose, which affects services’ ability  to deliver safe care. 

 

A nuanced workforce discussion is essential to delivering safe care: first by defining what ‘safe care’ means, and then identifying the workforce required to achieve it. This must be underpinned by a robust assessment of maternity and neonatal services’ capacity and demand, including workforce modelling across all staff groups. 

 

Monitoring and evaluation must be central to the final report. The impact of this investigation and its recommendations should be measured by improvements to birth outcomes. We have called for the government to set  set new ambitions for reducing perinatal mortality and preterm births, focused on matching the best-performing countries in Europe. Routine data collection to monitor the rate of miscarriage should also be implemented so trends over time can be analysed. 

It is critical that the investigation leads to meaningful action, ultimately making maternity and neonatal services safer and improving outcomes, for all.