Today, 30 June, the final report of the Independent Investigation into Maternity and Neonatal Services in England has been published. The report is the conclusion of a rapid national investigation into NHS maternity and neonatal services which was ordered by the Secretary of State for Health and Social Care in June 2025.
Caroline Lee-Davey, Chief Executive of the UK’s leading neonatal charity Bliss, commented: “It is deeply disappointing to read this report, which displays a fundamental misunderstanding of neonatal care as distinct from maternity care and singularly fails to recognise babies as patients in their own right. After nearly a year of work, and extensive engagement with families, staff and stakeholders across the country – whose voices, especially those of dads, have been minimised in the final report – it is baffling how limited the report is in its analysis of neonatal care and the improvements needed within it.
“Most worryingly, the Investigation does not recognise neonatal services as a distinct, specialised service with an entirely different patient population. We are concerned that the recommendations – particularly regarding a Maternity and Neonatal Commissioner and development of a new Modern Services Framework – could potentially be damaging to the well-established and evidence-based structures within neonatal services if they are implemented on the basis of this flawed understanding.
“Critically, the Investigation has made no attempt to understand variations in quality of neonatal care delivery, the impact of Family Integrated Care – which enables parents to be partners in delivering their baby’s care and decision-making – in supporting babies to have the best outcomes, and only a limited assessment of how racism and discrimination affect care in neonatal settings specifically. It is also extremely concerning to see in the report’s findings on workforce, no reference at all to allied health professional, pharmacy and psychology staffing or neonatal nursing levels, despite these being fundamental to ensuring babies receive safe care.
“Bliss engaged with the Investigation Team in good faith throughout their work: we provided extensive written evidence, contributed to multiple roundtable events, and facilitated two evidence sessions with neonatal parents which focused exclusively on their experiences of neonatal care. While we have had concerns about the approach of the Investigation, we have engaged constructively throughout, and sought to highlight both areas of good practice and areas for improvement within neonatal services. It is extremely disappointing not to see this input reflected in the report, and we are particularly concerned that the voices of parents have been largely absent.
Caroline Lee-Davey added: “While we welcome several of the specific recommendations which do relate to neonatal care – in particular the recommendations that there should be universal provision of transitional care and neonatal community outreach, as well as a standardised neonatal palliative care model – these do not outweigh the fact that, after a year of work, this report is a significant missed opportunity in setting out a clear improvement plan for neonatal services to ensure that every baby born premature or sick has the best chance of survival and quality of life.”
Bliss’ CEO Caroline Lee-Davey sits on the Charity and Third Sector Expert Reference Group of the Maternity and Neonatal Taskforce, and through this role will be seeking to clarify as a matter of urgency how neonatal services may be included in the action plan to be developed over the coming months. Bliss remains committed to working with national, regional and local bodies alongside families and health professionals to support neonatal service improvement, and will publishing our own report, ‘Equity for Every Baby’, on Thursday 2 July, which will focus on neonatal inequalities based on ethnicity and deprivation.
