National Maternity and Neonatal Investigation FAQs
This page has answers to some frequently asked questions (FAQs) about the National Maternity and Neonatal Investigation
Why has this report been published?
This report is part of a national review of maternity and neonatal services across England, led by Baroness Valerie Amos. It draws on evidence from 12 site visits, more than 450 family interviews, 10,500 family responses, 9,000 staff responses and national stakeholder engagement. It is not a regulatory inspection of individual Trusts. It looks at safety, quality of care, and the experiences of women, babies and families, with a particular focus on inequalities and how services respond when things go wrong.
Why was Gloucestershire Hospitals NHS Foundation Trust included?
The Trust was selected as part of a group of NHS organisations to help understand how maternity services are working across the country. The investigation included reviewing Trust data, speaking to staff and leaders, and hearing directly from families about their experiences. There are no recommendations directed at individual Trusts. The local Trust reports are snapshots intended to support national learning and improvement.
What is the Trust’s response to the report?
We are deeply sorry to the women, babies, families and our staff whose experiences of our maternity and neonatal services did not meet the standards they have the right to expect. We are committed to being open about where we need to improve and to making real, lasting changes so that every woman, baby and family receives safe, compassionate and high‑quality care.
Are your maternity services safe?
Our maternity services have never been safer in Gloucestershire. That is because of the improvements we have made over the last four years to how we monitor safety and respond when things do not go to plan. We know there is more to do, and we are continuing to improve how we manage demand and reduce delays. Following the Amos Team update, maternity triage will be an immediate area of focus, including how calls are answered, how concerns are escalated, waiting times, capacity and Board oversight.
What are you doing to improve leadership and culture?
We know that leadership and culture have a direct impact on the care people receive. We’ve strengthened leadership, increased senior support, and invited external review to speed up improvement. We want women to feel heard and staff to feel supported. We recognise this is an area where trust needs to be rebuilt, and we are continuing to work on making these improvements consistent across all parts of our service.
How are you addressing racialised and social inequalities in care?
We recognise that not all women and families experience care in the same way, and that inequalities exist. We are working to understand this better through local data and engagement with communities. We are also supporting staff, including our Board and senior leaders, to take part in Black Maternity Matters training to improve awareness and provide more inclusive care. We know that training alone is not enough. We are continuing to focus on reducing inequalities and making sure improvements are visible in people’s experiences and outcomes.
Are your facilities suitable for maternity care?
Our main maternity services are based in the Women’s Centre at Gloucestershire Royal Hospital, a purpose-built facility where maternity, neonatal and specialist services are all in one place. This helps us provide joined-up care, especially for women who need additional medical support. However, we know that not all areas of our buildings are where we want them to be. We are making sure care is delivered safely now while planning improvements for the future to improve privacy, comfort and overall experience.
Do you have enough staff?
Our staff are at the heart of the care we provide, and they come to work every day to do a job they love. Like many maternity services nationally, staffing has been a challenge, but there have never been more midwives and obstetricians working in Gloucestershire than there are today. However, like many NHS services, we still face workforce pressures. We are continuing to invest in recruitment, training and staff wellbeing to ensure we can provide safe and consistent care.
Why have some services, like home births or birth units, been temporarily unavailable?
In some cases, we have taken the difficult decision to temporarily change or pause services when we cannot provide them safely. For example, home births have been suspended at times following safety concerns raised by staff and a detailed risk assessment. We understand how important choice is, and our aim is always to restore options as soon as it is safe to do so.