Recommendation 4

HM Government Accepted

The government strongly agrees with the conclusion of the committee that progress has remained too slow in improving Black maternal health. Too many women and families have suffered trauma, harm and loss due to failures in maternity care, particularly in ethnic minority communities, including women from Black ethnic backgrounds. That is why we announced, in June 2025, a national independent investigation into NHS maternity and neonatal services, which will help us to understand the systemic issues behind why so many women, babies and families experience unacceptable care. On 14 August 2025, the Secretary of State for Health and Social Care announced the appointment of Baroness Amos as chair of the investigation. The investigation will gather evidence directly from women and families, including fathers and non-birthing partners, to ensure their lived experience is reflected and used to inform recommendations. The investigation will bring together the findings of past reviews into one clear national set of actions to ensure every woman and baby receives safe, high- quality and compassionate care. Baroness Amos will be working closely with families as the investigation develops and, on 9 December 2025, published reflections (linked previously in the introduction) on what she has heard so far. The investigation’s final report and recommendations will be published in spring 2026. The investigation is independent and the terms of reference for the investigation (linked previously in the introduction) were published on 15 September 2025, which include a focus on inequalities. The investigation will aim to identify the drivers and impact of inequalities faced by women, babies and families from Black and Asian backgrounds, deprived groups, and other marginalised groups when receiving maternity and neonatal care. This will include: • focusing on factors such as racism, discrimination, lack of culturally sensitive care and language barriers • exploring how past experiences influence care-seeking behaviour • seeking opportunities to reduce health inequalities and promote equity We support the priorities outlined by the Health Services Safety Investigations Body, specifically the defining of an accountability framework for maternity and neonatal services. As set out in the terms of reference for the independent investigation, it will assess the quality of the response of NHS trusts and ICBs when things go wrong or harm occurs, including investigating and learning from incidents, and promoting honesty, transparency and candour. Further, the investigation will examine the response of local and national healthcare organisations to women, babies and families when things go wrong or harm occurs, including preventable deaths and harm, during the delivery of maternity and neonatal care. This will include reviewing how healthcare investigations are undertaken, including establishing accountability. The investigation did not include consideration of funding in its published terms of reference. The government has provided a detailed response to the commission’s recommendations (9 and 10) in the section on ‘Funding’ below. The recommendations made by the investigation will be addressed by the National Maternity and Neonatal Taskforce, which will be chaired by the Secretary of State for Health and Social Care and formed into a national action plan. The taskforce will work closely with families and stakeholders in developing the action plan, ensuring their voices are central to this work - including those from more marginalised groups and those experiencing worse outcomes. Workforce