Today, HSSIB has published it’s report An exploratory review of maternity and neonatal services. The report summarises information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This 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 exploratory report identified that the following areas required 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
In response to the findings, Professor Ranee Thakar, President of the Royal College of Obstetricians and Gynaecologists said:
“This exploratory report comes at a critical moment, as the rapid national review of maternity and neonatal safety gets underway. While there are some questions over its methodology, it offers valuable insights that should be considered carefully, highlighting some of the most pressing challenges facing maternity services - many of which will resonate strongly with teams determined to provide the best possible care for women and families.”
“We welcome the recognition that, while there is significant work already underway to improve services, this remains uncoordinated. The report rightly identifies the chronic underfunding of maternity and neonatal services as a barrier to change, and echoes what the College and frontline staff have long warned: there are too many safety recommendations for overstretched services to manage, and no organisation with clear accountability for implementation. Services urgently need a clear set of priorities, so they know exactly where to focus their efforts.
“This exploratory report acknowledges the impact that high-profile maternity inquiries have - not only on public confidence in services, but also on the professionals delivering them. The College has been clear: appropriate support must be provided to all Trusts and the families they support, and especially to those that are selected to take part in the forthcoming rapid national review.
“The review recognises the complexity of maternity systems and suggests that a safety science approach can help explain how local components contribute to the overall functioning of a unit. This evidence-based approach should be considered.”
“Everyone in maternity services, from board to ward, wants to find a way forward. We must now synthesise the learning from this report with the wealth of existing evidence and work collaboratively to deliver lasting solutions. Too many women and babies are still not receiving the safe, compassionate care they deserve, and the workforce remains under immense pressure. Evidence from multiple investigations has identified these same challenges time and again. It is now time to act.
“We therefore urge the Chair of the rapid national maternity review and the expert advisory group to consider these findings closely in shaping the review’s conclusions.”
- Read the RCOG's response to the announcement of the rapid national review of maternity and neonatal safety here.
- Read the RCOG's response to the announcement of the Chair of the rapid national review of maternity and neonatal safety here.
- More information on the RCOG Maternity Safety programme is available here.
- Additional help and support is always available for our membership via our support services: https://www.rcog.org.uk/careers-and-training/workforce/supporting-our-doctors/wellbeing-resources-hub/