Since the publication of the final report of the Maternity and Neonatal Investigation on 30 June, questions have been raised about the review process, which should be answered. Notwithstanding these issues, the focus must be on the report’s conclusion that the “maternity and neonatal system is not set up to deliver consistently safe, high-quality and compassionate care” and the need for systemic and cultural change. As the report itself points out, the problems that the investigation has identified are not new, but we welcome the recognition that these are issues across all services and not limited to ‘darker corners’ of the NHS.

We welcome the call for fundamental reform and redesign of maternity services, which puts safety, equity and compassion at the centre. But while the Investigation took ten months to review the issues, the Taskforce will be asked to design the solutions in just six months. This process should not be rushed, especially as the Taskforce is not limited to the report’s recommendations and should properly consider neonatal care as a distinct service.

The Government, guided by the Taskforce, must go back to basics. Our research found that there is not a shared understanding of what ‘safe care’ means, with some focusing on reducing preterm birth and baby deaths while others focus on improving patient experience. A shared understanding of what physical and psychological safety means for maternity and neonatal care must be the starting point, followed by a discussion of how to deliver it.

This must include completely reassessing how care is delivered across community and clinical settings; the digital and physical infrastructure required; what staff learn, their beliefs and behaviours; and how different professions can work together better.

The report has called for the appointment of a Maternity Commissioner, which has been accepted by the Government. While a Commissioner may help to improve Parliamentary oversight but should be in addition to efforts to improve governance systems and accountability. This must include reviewing the role of regulators, removing duplication and improving their effectiveness, and considering how to move Trusts, Integrated Care Boards and the wider NHS away from reputation management towards genuine accountability and learning when things go wrong.

Finally, we welcome the focus on data and evaluation moving forwards. The Investigation noted the volume of overlapping recommendations for maternity and neonatal services over the past decade, which are often not evidence-based nor evaluated. This approach is not working. In England, the stillbirth rate in 2025 and the neonatal mortality rate in 2024 (the latest data for each) were the same as in 2019. Data and evaluation must be integral to deciding what works and should be prioritised, but also, importantly, what should be stopped.

The Health Secretary, James Murray, has said this will be a “watershed moment” for maternity services. We have called for the Government to set new ambitions to reduce pregnancy loss, baby deaths and preterm birth alongside eliminating inequalities, which should be the metrics that success is measured against to make birth safer, for everyone.