The report from Baroness Amos calls for urgent reform for maternity and neonatal care to put safety at its centre, embedding a focus on listening to women and ensuring anti-racist practice at every level.

Baroness Amos said: ‘Too often, this investigation heard that people were not listened to, that harm was repeated and that families were left without clear answers or accountability when things went wrong.

‘This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it.

‘These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability and create a system that learns when harm occurs.'

The report sets out eight recommendations to redesign the maternity and neonatal system and deliver fundamental change:

• the creation of a statutory national Maternity and Neonatal Commissioner to drive the urgent, systemwide change identified by the investigation and provide leadership for a redesigned maternity and neonatal system, through the Health Bill currently before Parliament
• systematically listening to the voices of women and families
• improving how the system responds when something goes wrong, including providing a sincere apology and learning lessons
• creating a modern service framework which sets out national standards to consistently achieve high quality maternity and neonatal care
• tackling racism, discrimination and inequality
• improving system governance and accountability structures and regulatory oversight
• improving culture and teamworking, and strengthening leadership at all levels of the system and across professions
• delivering estates and digital systems that are fit for modern maternity and neonatal care.

Health and Social Care Committee chair, Layla Moran, said: ‘After so many reports on failing maternity services, this must be the last. We must now turn the recommendations into reality, not allow them to gather dust like so many reports before. I welcome proposals for a new Commissioner and Taskforce, but without leadership at the top of Government, and the necessary funding, we will be back here again asking the same questions.'