NMC responds to Independent National Maternity and Neonatal Investigation

Baroness Amos’s report is the latest in a succession of investigations over the past 12 years – from Morecambe Bay and Shrewsbury and Telford to East Kent, and the review of Nottingham University Hospitals published only days ago – that describe the same devastating pattern: women not listened to, warning signs missed, mistakes not admitted, and families left without answers. Many families have spent years fighting simply to be heard. 

The NMC provided evidence to Baroness Amos’s review – and says these are not isolated tragedies but evidence of systemic failure for which the whole system, including its regulators, must take responsibility. The NMC recognises that it has an important role in learning from these failures and has apologised for its failings to the affected families involved in the recent Nottingham maternity review.

In recognition of the devastating ongoing impact of racism, discrimination and inequality in maternity services – which is highlighted in the Amos report – the NMC published, in May, new anti-racism principles for midwifery and nursing education and practice.

The NMC will work closely with the Government and contribute to its full response to the Ockenden and Amos reports and will feed into the National Action Plan, recently announced by the Secretary of State, which will be published in December. 

Paul Rees MBE, Chief Executive and Registrar of the NMC, said: 

“Where the NMC has been too slow to react in the case of maternity failings, where it has allowed Fitness to Practise cases to go on for too long, and failed to take a trauma-informed, families first approach, I am truly sorry.

“As the regulator of nurses and midwives, we must take responsibility for where we have fallen down, as part of the system.

“We need to improve our response to maternity failings, to ensure that we listen, learn and change the way we do things. We need to make sure that we are open about where cases are within our Fitness to Practise process – and we need to ensure that the Fitness to Practise process, itself, is as timely as possible. We need to get better at communicating with families involved in Fitness to Practise processes, and we need to make the process as accessible as possible.

“In addition, we need to make sure that the education standards that we set for midwifery programmes, across the four nations of the UK, are fit for the future and address the issues that have emerged from the reviews of maternity failings.

“We are currently consulting on a proposal to extend midwifery education to four years in order to tackle some of the challenges that have been highlighted by the reviews – and we are very open to ideas and proposals around how our ideas for improving midwifery education can be further strengthened and improved.

“We will now fully consider the findings of the Amos review and take clear, measurable actions to ensure that the changes we make are fully embedded in how we regulate.

“We will work with the National Maternity and Neonatal Taskforce to deliver the recommendations that fall to it.”

He added: “We welcome the Government’s announcement, in response to the Amos report, that a new Maternity and Neonatal Commissioner will be created. This post will play a key role in strengthening oversight of maternity and neonatal services.

“We welcome the recommendation that the Department of Health and Social Care and NHS England should clarify existing system governance, oversight and accountability structures, and improve the effectiveness of regulatory oversight, within nine months, and we will play our part in this.”

The NMC’s primary purpose is to protect the public. It sets the standards that nurses, midwives and nursing associates must meet, decides who is fit to join and remain on the register, quality-assures the education of future professionals, and acts when a professional’s practice puts people at risk.

Baroness Amos, and many affected families, have called for the role of regulators to be examined so that trust can be rebuilt, and for systems of regulation that are rigorous, accessible and responsive when families need them. 

The NMC has already committed to the following specific actions, with clear timescales against which its progress can be measured: 

• Embedding the anti-racism principles for midwifery and nursing education and practice. Black, Asian and ethnic minority women and their children are more likely to die, or suffer harm during pregnancy, childbirth or after birth. The NMC’s principles launched in May – as a direct response to the Black maternal health crisis – will help tackle these unacceptable health inequities. The principles will help embed anti-racism, bias awareness, cultural curiosity, safety and respect across midwifery and nursing education and practice. This is a non-negotiable thread through all its standards work.
• Listening to families directly and improving how concerns are raised and acted upon. Building on the case surgeries that have been held with affected families in Nottingham, and the public information developed with Donna Ockenden’s support, the NMC will improve the process of making referrals and make it easier for women and families to raise concerns and to understand the regulator’s processes. 
• Strengthening midwifery education and preparing students for safe professional practice. We are consulting on proposals to make sure midwifery students gain the knowledge, skills, professional behaviours and experience needed to deliver safe, kind and effective care when they qualify. This includes a proposal to increase the minimum length of pre-registration midwifery programmes from three years to four years, alongside other changes to strengthen education and support the transition into professional practice.
• Modernising the Code. Strengthening the standards every nurse and midwife must uphold – to set clearer, stronger expectations on behaviour, candour and listening to women, responding directly to families’ experience of not being heard. The NMC will consult from September to December 2026, with the modernised Code coming into effect from Autumn 2027. 
• Resolving sensitive cases more effectively and without unnecessary delay. Further to the case handling improvements we have established for families affected by maternity care failings in Nottingham, the NMC will continue to work towards a more consistent, joined-up, compassionate and trauma-informed approach for affected families across the UK. Its wider Fitness to Practise (FtP) improvement plan is also focused on improving the FtP system end-to-end, making it faster, fairer, more consistent and less distressing for everyone involved.
• Supporting professionals to give safe care. Together with the General Medical Council, the NMC is promoting better multidisciplinary teamworking through a ‘Good teamwork means better maternity care’ project, helping create the conditions for safe care. 
• Reporting on progress openly. The regulator will work with the National Maternity and Neonatal Taskforce to deliver the recommendations that are relevant to it and will be transparent about progress – so that families, professionals and the public can hold the regulator to account.

The NMC is contributing to the Regulators and Investigatory Bodies expert reference group as part of the National Maternity and Neonatal Task Force. This work will help to address systemic safety and accountability issues from a regulatory perspective across maternity and neonatal services.

The NMC will continue to engage with affected families, professionals, partners and the public as it delivers these commitments and will report on its progress, contributing to regular updates so that Government can clearly assess the progress being made.

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