An exploratory review of maternity and neonatal services

This report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Healthcare Safety Investigation Branch (HSIB), the precursor organisation to HSSIB. Although we consider this information to be limited in its breadth and depth compared to a full HSSIB investigation, the exploratory exercise did provide evidence to support the direction any future investigations might take.

On 23 June 2025, the Secretary of State for Health and Social Care announced a national investigation into maternity and neonatal services. The intention is that this investigation will be rapid, system wide and report in December 2025. In light of this announcement, we paused our intention to progress investigations into maternity and neonatal services, recognising that it would be prudent to wait for the outcome of the national investigation. However, we considered that the information we collected during the exploratory review was important and could assist the national investigation. Therefore, we decided to publish this summary report.

During spring 2025 we undertook an exploratory review of maternity and neonatal services with the intention of using the information we collected to inform potential areas for investigation. Following the announcement of the Secretary of State for Health and Social Care’s national investigation into maternity and neonatal services in June 2025, we have paused this work.

We are sharing the insights we gathered during this exploratory work to assist the national investigation announced by the Secretary of State. Some of these insights are consistent with the areas identified in other investigations and reviews of maternity care, while others have emerged from the information we have gathered.

Our exploratory review identified the following areas that require further investigation:

• the national structures responsible for providing direction and oversight for maternity services
• local governance arrangements for NHS maternity services and their relationship to national bodies
• the standards and approach of local investigations when things go wrong
• education, training and professional standards for clinicians providing maternity and neonatal services.

1. Some improved outcomes
   Some progress has been made in maternity and neonatal outcomes, staffing levels and governance arrangements.
2. Complex national infrastructure
   National maternity and neonatal systems are overly complex.
3. Collaboration and information sharing between national organisations
   National collaboration efforts are inconsistent and variable.
4. Development, oversight and implementation of recommendations
   Too many recommendations exist, with limited implementation.
5. Local governance arrangements
   Local governance of maternity services often operates in isolation from the wider organisation
6. Risk awareness
   Services still lack the consistent ability to identify and respond to clinical risks.
7. Potential for learning in maternity and neonatal services
   There is limited potential to learn from harms that happen to women and babies during pregnancy, labour and birth.
8. Compounding patient harm
   Patients experience compounded harm due to issues within the wider healthcare system, particularly the way local investigations are carried out or the way complaints/concerns are managed.
9. Compounding staff harm
   Staff are also affected by cumulative stress and harm.
10. Inequalities
    Disparities in care and outcomes persist because of health inequalities.
11. Training and standards
    There are concerns about the standards set in undergraduate and postgraduate education and whether these can be adhered to in practice.