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Learning reports and RCOG responses

Find current national learning reports and, where applicable, RCOG responses to recommendations.

Department of health and Social Care commissioned reports 

a. National Maternity and Neonatal Investigation. Baroness Valerie Amos June 2026

Baroness Valerie Amos was appointed to chair the National Maternity and Neonatal Investigation on 14 August 2025. The rapid, independent investigation had been ordered to provide truth to affected families and drive urgent improvements in patient care and safety. It was also part of a wider package of actions to boost accountability and safety in the NHS. The investigation examined maternity and neonatal services in 12 NHS Trusts, but also across the whole maternity system, incorporating the views of affected families and their representatives. It has developed a set of national recommendations to drive improvements in maternity and neonatal care across England, reduce inequalities in the delivery of these services and help affected families to receive justice and accountability. 

Read the College's response.

b. The Independent Maternity Review of Nottingham University Hospitals NHS Trust. Donna Ockenden June 2026

This Review has been established by NHS England in May 2022, following significant concerns raised regarding the quality and safety of maternity services at Nottingham University Hospitals NHS Trust (NUH) and concerns of local families. This review replaces a previous regionally led review after some families expressed concern and made representation to the SoS at DHSC. Donna Ockenden is leading a team of experienced doctors and midwives working in maternity services to review cases of serious and potentially serious concern in maternity services at Nottingham University Hospitals NHS Trust. 

Read the College's response.

Reading the signals: Maternity and neonatal services in East Kent 2022

CoverThe report of the independent investigation led by Dr Bill Kirkup on Maternity and Neonatal Services in East Kent. The key points from this report details that between 2009 and 2020 at the two hospital sites, The Queen Mother Hospital in Margate and the William Harvey Hospital in Ashford, the Trust provided clinical care that was “suboptimal” and led to significant harm. The report shows that, during this period, there were multiple missed opportunities that should have led to problems being acknowledged and tackled effectively. If care had been given to the nationally recognised standards, the outcome could have been different in nearly half of the 202 cases assessed by the Investigation’s panel.  The outcome could have been different in 45 of the 65 baby deaths ­–­ more than two-thirds of cases. The report acknowledges that it includes “minimum estimates” of the frequency of harm, with the panel having only worked with families who volunteered to be involved in the report. Alarmingly, the panel has “not been able to detect any discernible improvement in outcomes or suboptimal care” in the decade between 2009 and 2020.

Ockenden Report

CoverDonna Ockenden led the review of Maternity services at Shrewsbury and Telford. It reports the tragic findings from 1,592 real clinical incidents of harm at The Shrewsbury and Telford Hospital NHS Trust (SaTH) between 2000-2019. The clinical incidents include stillbirths, neonatal deaths, maternal deaths, and cases of hypoxic ischaemic encephalopathy (HIE; a brain injury caused by a lack of oxygen or blood flow during labour). The report demonstrates a need for support and investment in SaTH and also in wider maternity services.

 

Arms Lengths Body Reports

CQC

The Care Quality Commission (CQC) has published its National Review of Maternity Services in England, setting out thematic findings and recommendations arising from 131 inspections carried out between August 2022 and December 2023. The review found continued concerns about the quality of NHS hospital maternity services, with common issues impacting safety. It warns that without urgent action and investment in services nationwide, there is a risk of poor care and preventable harm to women and babies becoming normalised.

The CQC’s report State of Health Care and Adult Social Care in England provides a comprehensive picture of the system, and the experiences of staff and patients.

The CQC’s ‘Safety, Equity and Engagement in Maternity Services’ presents an analysis of the key issues persisting in some maternity services and highlights where action is still needed to support vital improvements.

CQC’s briefing Getting safer faster: key areas for improvement in maternity services highlighted continued concerns about the variation in quality and safety of maternity services across the country.

Despite the greater national focus on maternity in recent years and the welcome improvements it has led to, the pace of progress has been too slow and action to ensure all women have access to safe, effective, and truly personalised maternity care has not been sufficiently prioritised to mitigate risk and help prevent future tragedies from occurring.

Following the publication of ‘Getting safer faster’ the CQC launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as team working and culture, staff and patient experience.

Reports from organisations/charities

MBRRACE Report

Cover'MBRRACE-UK' is the collaboration appointed by the Healthcare Quality Improvement Partnership (HQIP) to run the national Maternal, Newborn and Infant clinical Outcome Review Programme (MNI-CORP) which continues the national programme of work conducting surveillance and investigating the causes of maternal deaths, stillbirths and infant deaths.

RCOG responses to clinical advancements 

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