Jump to 28 Recommendations

The Path to Safer Beginnings in Wales: National Assurance Assessment of Maternity and Neonatal Services

Wales
Published 25 Feb 2026
Investigator NHS Performance and Improvement

National assurance assessment of maternity and neonatal services across Wales, commissioned by the Cabinet Secretary for Health and Social Care in May 2025. Chaired by Professor Sally Holland (former Children's Commissioner for Wales). The panel visited maternity units throughout Wales and consulted hundreds of women, families and staff. Identifies strengths and vulnerabilities across capacity, culture, racism and discrimination, accountability, estates and workforce. All recommendations accepted by Welsh Government with three-year phased delivery programme.

Report PDF NHS England Source
Acceptance Status
Accepted 28
Total Recommendations 28
About this data

Acceptance Status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

Recommendations (28)

1a Welsh Government, NHS P&I
Accepted
Recommendation
The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, … Read more
1b Welsh Government, NHS P&I
Accepted
Recommendation
A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly … Read more
1bi Welsh Government
Accepted
Recommendation
We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on … Read more
1bii Welsh Government
Accepted
Recommendation
The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that … Read more
1c Welsh Government, NHS P&I, Health Boards
Accepted
Recommendation
Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group … Read more
1d Welsh Government, NHS P&I
Accepted
Recommendation
A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report. Read more
2a Welsh Government, HEIW, Health Boards, HEI
Accepted
Recommendation
We recommend that current rates of continuity of care by midwives are assessed in 2026–27, and that a meaningful, co produced plan is developed to increase continuity of care.
2b Welsh Government, HEIW, Health Boards, HEI
Accepted
Recommendation
All maternity, neonatal and relevant education providers to actively progress through the stages of UNICEF UK Baby Friendly Initiative accreditation.
2c Health Boards
Accepted
Recommendation
Health Boards should ensure that a birth discussion takes place with a suitable member of the multidisciplinary team involved in their care, before discharge from maternity services.
2d Welsh Government
Accepted
Recommendation
We recommend that Welsh Government supports Health Boards by providing clear, accessible and evidence-based public information resources, to enable consistent, accurate and timely communication with women, families and communities at a regional and local level. Read more
3a Welsh Government, NHS P&I
Accepted
Recommendation
Welsh Government should progress at pace in 2026 with commissioning and implementation of the national triage line and publish a standardised national model for in person triage.
3b NHS P&I
Accepted
Recommendation
A national service specification should be developed to ensure consistent alignment with evidence-based guidance on informed decision-making, care planning and timely access to care. This should include a standardised service model setting out admission pathways, place of care, dedicated staffing, … Read more
4a HEIW
Accepted
Recommendation
A multidisciplinary maternity workforce planning tool should be developed and implemented to align and integrate with BAPM standards for neonatal services. This tool should cover the full maternity pathway and include adequate provision for allied health professionals, psychology and pharmacy, … Read more
4b Health Boards
Accepted
Recommendation
Health Boards must address immediate staffing pressures while national workforce specifications for maternity services are redeveloped. Health Boards must undertake a comprehensive review of obstetric workforce capacity taking account of service complexity, links with gynaecology, geography, and workforce sustainability. Health … Read more
4c NHSWJCC, NHS P&I
Accepted
Recommendation
A review of clinical pathways for rare but serious pregnancy-related conditions, to ensure clear, consistent and commissioned routes to expert care within Wales or, where required, across the UK.
4d Welsh Government, Health Boards
Accepted
Recommendation
Should review maternity theatre estate, capacity and staffing to ensure theatres are appropriately located, equipped and resourced for planned and emergency surgery.
5a Welsh Government, NHS P&I, Health Boards
Accepted
Recommendation
Develop and publish a national service specification for perinatal mental health pathways covering common and moderate to severe mental health needs, services for fathers/partners, and parent–infant relationships.
5b Health Boards
Accepted
Recommendation
Health Boards should embed trauma-informed training for all perinatal staff and those involved in incident processes and work collaboratively with staff to understand wellbeing needs and coproduce effective, monitored support arrangements.
6a NHSWJCC, Health Boards
Accepted
Recommendation
The NHS Wales Joint Commissioning Committee should urgently complete analysis and commissioning decisions on neonatal cot configuration, neonatal transport and transitional care capacity.
6b NHSWJCC, Health Boards
Accepted
Recommendation
The Welsh Government should accelerate implementation of a national maternity bed and neonatal bed/cot locator with 24/7 availability, dedicated staffing, senior clinical oversight and a single point of access.
7a NHS P&I
Accepted
Recommendation
A clear, accessible and publicly available Standard Operating Procedure for maternity and neonatal incident response should be published for Wales underpinned by family-centred, trauma-informed and restorative approaches.
7b Welsh Government, NHS P&I, Health Boards
Accepted
Recommendation
A specialist sub-committee of the National Strategic Oversight Board should oversee Health Boards' delivery of the perinatal National Reportable Incident process, ensure timely, multidisciplinary and family-centred responses, and produce national thematic learning. Read more
7c NHS P&I
Accepted
Recommendation
A national perinatal incident repository to enable systematic learning from local and national reportable incidents.
8a Health Boards
Accepted
Recommendation
Improve how women's, families' and communities' experiences and views are heard and acted on by optimising the implementation of the Perinatal Engagement Framework.
8b Health Boards
Accepted
Recommendation
Improve how the experiences and views of staff are heard and acted upon by implementing meaningful involvement approaches that are co-produced with staff groups.
8c UK Government, Welsh Government
Accepted
Recommendation
A programme of research on the costs and short, medium and long-term consequences of the current and emerging model of care.
8d Health Boards
Accepted
Recommendation
Test and evaluate initiatives to reduce inequalities of experience and outcome, particularly relating to poverty and ethnicity, and share findings.
8e Welsh Government
Accepted
Recommendation
Commission an evaluation of the impact and outcomes of the priorities recommended here.