- 1 July 2026
Responding to the publication of Baroness Amos’s independent investigation into maternity and neonatal services in England, the Chartered Governance Institute UK & Ireland (CGIUKI) said the findings place governance, accountability and culture at the centre of why services have failed and how they must now improve.
Linda Ford, Chief Executive of CGIUKI, said:
“The Amos investigation concludes that England’s maternity and neonatal system requires significant reform if it is to deliver consistently safe, high-quality care. It describes a system that is fragmented, overly complex and too slow to learn.
“What makes this investigation significant from a governance perspective is its focus on accountability, oversight and culture. It does not only ask whether services are delivering the right outcomes. It asks whether the systems responsible for those outcomes are working as they should.
“The findings on racism and discrimination are especially serious. Culture is not separate from governance. It is one of the clearest indicators of whether governance arrangements are working as intended, and a system in which some women receive poorer or less safe care because of their race is a system whose governance is not working.
“The investigation also exposes how difficult accountability becomes when responsibility is shared across many organisations, where it can end up owned by none. The government’s decision to create an independent Maternity and Neonatal Commissioner responds to that, and a clear, independent point of accountability is a sound governance principle. But a new structure is only as good as the understanding it is built on. It must reflect the full range of services it oversees, each with its own needs and risks, and it must simplify the system rather than add another layer to it. Governance that does not fit what it governs will not make services safer.
“This investigation is a reminder that governance is not a back-office function or a compliance exercise. When it works, it is what allows an organisation to see problems early, face them honestly and keep the confidence of the people it serves.
“The real test now is implementation. Many of these problems have been identified before, and the recommendations that followed were too often not delivered, or allowed to lapse. Families will rightly judge this moment not by the words written today, but by the change that follows in the years ahead.”