National Maternity and Neonatal Investigation Report published

The National Maternity and Neonatal Investigation report, led by Baroness Amos, has been published.

We recognise this is difficult reading, with some distressing accounts from women, families and staff across the country and locally.

Our Trust was one of 12 organisations included in the national review. The local Trust reports are intended as snapshots of services to help inform national learning; they are not regulatory inspections, do not provide Trust ratings and do not make recommendations directed at individual Trusts.

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 recognise the lasting impact this has had.

We are also deeply concerned by the accounts of discrimination and wider social inequalities experienced within maternity services. We know there is more to do, and we are committed to improving the consistency, safety and quality of care for every family.

What the report means for Gloucestershire

The themes in the report are not new. They reflect issues we have already identified through CQC inspections, independent reviews and feedback from women, families and staff.

We are already taking action, but the report reinforces the need for improvement to be more consistent, visible and clearly understood.

We will review the final recommendations carefully and set out clearly what further action we will take, working with women, families, our independent Maternity and Neonatal Voices Partnership, system partners and regulators.

Nationally, the Secretary of State will establish a taskforce to consider Amos, Ockenden and existing maternity requirements, with the aim of creating one coherent national action plan.

We welcome this approach given the volume of previous recommendations and the need for sustainable improvement.

Improving our services.

In 2024, we commissioned independent reviews into maternal and neonatal deaths to ensure we fully understand where care fell short and to strengthen learning and accountability.

We are continuing to work directly with affected families to ensure their voices are heard.

We are improving how we listen and respond to feedback, recognising that feeling heard, respected and involved is fundamental to safe and compassionate care.

We will also ensure maternity triage is reviewed as a critical safety system, including call handling, escalation, waiting times, capacity, flow and Board oversight.

Nationally and locally, maternity care is becoming more complex. Women are having babies later, obesity rates are rising, and almost half have two or more long‑term health conditions.

As a result, more births involve intervention, with 45.1% of babies born by caesarean section in February 2026, compared with 36.0% in 2023 in Gloucestershire.

This has a direct impact on how services are delivered. A natural (physiological) birth is usually midwife‑led, involving 1–2 midwives (sometimes with a support worker), with shorter stays, often discharge within hours. By contrast, a caesarean is an operation involving around 8–10 staff, including obstetricians, anaesthetists, midwives and a full theatre team, with longer hospital stays and recovery.

We are continuing to reshape our services so they can safely meet these changing needs, including plans for the safe reopening of services in Cheltenham and the return of home births when it is safe and sustainable to do so.

This work is being developed with staff and our communities to ensure services meet the needs of local families now and in the future.

Alongside this, we are strengthening our culture, leadership and workforce, and placing a strong focus on communication, equity of care and staff support.

Our current position

The report also reflects that many families receive good care. Women’s experience of labour and birth in Gloucestershire was better than average, with other areas broadly in line with similar trusts.

This is consistent with the most recent CQC National Maternity Survey, where Gloucestershire was one of a small number of trusts rated better than expected overall. Outcomes for babies are also in many areas comparable to or better than similar Trusts.

However, there is still more we must do to ensure good care, shaped around choice, is consistent for every family, every time.

We are committed to being open, learning from the report and strengthening the improvements already underway to support women, families and staff now and in the future.

Chief Nurse Matt Holdaway said: “The latest Ockenden report and Amos report are painful reminders of what can happen when women and families are not listened to or involved in decisions about their care.

"Behind every finding are real people, real experiences and, for some families, deep hurt and grief. We know that saying sorry is not enough; people need to see that we have listened, learned and are making real changes.

"Many of the issues in these reports are already known to us and have shaped the work we have been doing over the last four years. But what matters most is how women and families experience our care. Where we have fallen short, we must be honest about that and act quickly and with humility.

"Maternity care is changing, and many women and babies now have more complex needs. Our responsibility is to make sure our services are safe, consistent and compassionate, and that women and families feel informed, respected and involved in their care.

"Our staff work hard every day to give the best care they can, often in difficult circumstances, and we are grateful for that. But hard work alone is not enough. We must make sure staff have the support, leadership, training and culture they need to give care that is safe, kind and centred on women, babies and families.

"We know there is more to do. We are working hard to safely reopen Cheltenham Birth Unit and our home births service and will be working with communities to ensure services are shaped around their needs."