The Maternity and Newborn Safety Investigation programme response to The Care Quality Commission (CQC) State of Care 2024 report. Katherine Hawes, Deputy Director (Investigations) of the Maternity and Newborn Safety Investigation Programme, said:

“Today’s annual State of Care report reiterates a number of key challenges within maternity services in England which were also recently highlighted in CQC's National review of maternity services in England 2022 to 2024¹. Too many women/ birthing people are not receiving the high-quality of maternity care they deserve and without concerted action there is a risk of harm becoming normalised.

“The report flags maternity as an ‘area of concern’ which is worrying not only to people using these services but also for staff working to deliver them.

“Challenges in recruiting and retaining staff, management of safety events, inconsistencies with triage, and inequalities in care and outcomes that persist in some services, all impact on the safety of care for women / birthing people. These are themes we see throughout our investigations.

“Inequalities in maternity care faced by black and ethnic minority women / birthing people are still a concern, and our work will continue to explore and understand these inequalities so we can work towards equitable outcomes for black and ethnic minority women / birthing people

“The next step for maternity and wider services is to continue to take on feedback to and work together to drive forward improvements. We will continue to provide our support and advice through our investigations to help ensure women / birthing people and their babies receive the best possible care.”

Notes to editors:

¹National review of maternity services in England 2022 to 2024 was published by the CQC in September 2024 and reviewed maternity services in England between 2022 to 2024.

About MNSI

The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England.

All NHS trusts are required to tell us about certain patient safety incidents that happen in maternity care. This is so that we can carry out an independent investigation and where relevant, make safety recommendations to improve services at local level and across the whole maternity healthcare system in England.

Throughout investigations we work closely with the families, NHS trusts and staff involved. We do not place blame on individuals or investigate individual members of NHS staff.

Our programme was established in 2018 as part of the Healthcare Safety Investigation Branch and is now hosted by the Care Quality Commission.

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