Baroness Amos was asked to write her report after a series of personal maternity scandals undermined many families’ trust in the NHS.
His team spoke to more than 450 families and visited 12 NHS hospitals in England to understand what changes were needed.
The main failure was that women and families were not listened to, which led to poor outcomes. There was a lack of a consistent standard of care, with large gaps in healthcare.
The report found that the system was “fragmented, overly complex and very slow to learn and improve”.
Baroness Amos called for urgent improvements to maternity triage services.
In her recommendations, Baroness Amos called for urgent improvements to maternity triage services, describing what she called “a rapidly expanding A&E service for maternity”.
As part of her recommendations, dedicated midwives should answer calls and provide timely advice, while women should be offered face-to-face appointments if they are still concerned. The report said that if those changes were made, they would save lives and reduce harm.
The investigation found that racism and discrimination should be considered serious safeguarding issues requiring immediate intervention, including the collection of data on disparate outcomes that can be escalated to board level if patterns emerge.
Speaking on BBC Radio 4’s Today programme, Baroness Amos said the system “is unsuitable now and in the future”.
“We need national standards to create maternity and newborn care against which we can test how trusts are working, how care is being provided,” she said.
She acknowledged calls from some families for a statutory public inquiry that would force senior people at the hospital trust to give evidence butsaid she did not support the idea.
“Statutory public enquiries take a very, very long time,” he said.
Based on my work and family conversations, I currently see no need for a statutory public inquiry, but that decision lies elsewhere.
The eight recommendations made in the report are:
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Appoint a National Maternal and Newborn Commissioner to drive change
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Hear the voices of women, birth parents and families
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Improve how the system reacts and learns when something goes wrong
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Set the national standard for achieving consistently high-quality care
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Tackle racism, discrimination and inequality
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Improve governance and accountability structures and regulatory oversight
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Improve culture and teamwork and strengthen leadership at all levels
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Provide digital systems and buildings that are fit for modern care
