The Health Services Safety Investigations Body (HSSIB) has shared insights into safety concerns raised by women, families, and other stakeholders about maternity and neonatal care within NHS England, highlighting the need for meaningful change.
On 23 June 2025, the Secretary of State for Health and Social Care announced a national maternity and neonatal services investigation. The intention is that the investigation will be rapid, system-wide, and reported in December 2025. The Government has indicated a commitment to uncovering failings at scale, standardising oversight, and improving patient safety across the country.
In spring 2025, HSSIB undertook an exploratory review of maternity and neonatal services, intending to use the information it collected to inform potential areas for investigation. The limited insights gathered have now been shared to assist the wider national investigation.
The HSSIB review paints a stark picture of systemic vulnerabilities that expose patients to avoidable harm. From October 2023 to June 2025, HSSIB received 35 safety concerns related to either maternity or neonatal services, highlighting recurring issues with communication, risk escalation, and adherence to clinical guidelines.
Only 35 concerns were reported in an 18-month period, which seems a very small number compared to all the reports of harm to women and babies, a fact that HSSIB accepts. However, from our experience as medical negligence lawyers, this is only the tip of the iceberg.
A level of disillusionment among stakeholders, including patients, clearly exists regarding the ability to bring about the required change, notwithstanding decades of inquiries and investigations. To counteract this disillusionment, HSSIB considers that any investigation needs to review the barriers to implementation.
Systemic failures
As stated above, the review highlights recurring issues with communication, escalation of risk, and adherence to clinical guidelines. From a legal perspective, these are not merely operational shortcomings – they can point to potential breaches of the duty of care owed to mothers and newborns. Cases where warning signs are missed or critical decisions delayed may give rise to claims of negligence, particularly where harm could have been anticipated and prevented with appropriate treatment.
Impact on families and evidential considerations
The report’s emphasis on patient harm – ranging from avoidable injuries to tragic fatalities – underscores the very human cost of these errors.
Professional accountability and institutional culture
Perhaps the most concerning from a legal perspective is the indication of cultural and structural barriers that inhibit timely escalation.
Accountability is not limited to individual clinicians; institutions may be responsible for failing to implement robust safety measures.
National investigation: context and implications
The Government’s national maternity and neonatal investigation reflects the seriousness of the systemic failings highlighted in the HSSIB review. This national investigation aims to provide a comprehensive, nationwide picture of maternity and neonatal safety, standardise oversight and identify areas for reform. From a medical negligence perspective, this demonstrates that the issues uncovered are not isolated incidents but part of a broader national pattern that has been ongoing for decades.
Rapid review: urgent lessons for safety
In addition, the rapid review announced by Wes Streeting focuses on urgent, high-priority lessons from maternity and neonatal care. While smaller in scale than the national investigation, it is designed to flag immediate risks and recommend swift improvements. From the legal perspective, its findings could influence standards of care and help to reinforce claims where harm could have been avoided. Although only a short-term review, it underscores the ongoing recognition by the Government that patient safety failures remain a critical concern.
A history of inquiries and continuing harm
Over the past two decades, multiple high-profile investigations, including the Ockenden Review, the East Kent Maternity Review, and numerous Trust-specific inquiries, have repeatedly exposed serious failings in maternity and neonatal services. Despite these repeated examinations and the recommendations that followed, HSSIB’s latest findings confirm that avoidable harm persists. Delays and missed warning signs, communication failures, and poor escalation continue to endanger mothers and babies, highlighting that systemic change remains incomplete.
Conclusion – looking ahead
While the reviews are positioned as learning and system improvement tools, they inevitably shape the landscape and context of medical negligence claims. Moreover, the report reinforces the need for proactive steps by healthcare providers to mitigate risk. Unfortunately, the ongoing failure to do so will have both clinical and legal consequences. The HSSIB review, together with the national maternity and neonatal investigation, is to our mind a sobering reminder that, despite ongoing efforts to improve care, systemic failings persist. Ensuring accountability, while advocating for safer standards of care, remains paramount.
about the authors
Sharon joined the Clinical Negligence and Personal Injury team as a Legal Director, in 2024, having previously been a Senior Associate at the firm between 2005 and 2016.
Asha is a Trainee Solicitor currently in her second seat with the Medical Negligence & Personal Injury team. Asha joined Kingsley Napley in September 2024.
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