National Maternal and Newborn Surveyexternal was created last summer by then Health Secretary Wes Streeting.
The aim of the report was to drive improvements across England after a series of maternity scandals undermined many families’ trust in the NHS.
Baroness Amos and her team spoke to more than 450 families and visited 12 NHS trusts to understand what changes were needed.
The key gap they identified was a failure to listen to women and families, which led to poor outcomes. There was no uniform standard of care and there was wide variation across health services.
The system is “fragmented, too complex and too slow to learn and improve,” Baroness Amos said in her report.
One of the urgent actions being urged for maternity units is an overhaul of their triage service, which Baroness Amos described as “increasingly becoming an emergency service for pregnant women”.
As part of this, midwives should answer calls and provide timely advice, and women should be offered a face-to-face appointment if they remain concerned. If these changes are made, the report says, “lives will be saved and harm reduced.”
Meanwhile, racism and discrimination must be treated as a critical safety issue, the study found, requiring urgent intervention, including the collection of detailed data on unequal outcomes that is escalated to the board level when patterns emerge.
Baroness Amos has acknowledged calls for a statutory public inquiry that would force senior figures from affected hospital trusts to give evidence. But she does not support such a move.
“Public inquiries take a very, very long time,” she told the BBC.
“Based on the work I have done and conversations with families, I do not see the need for a statutory public inquiry at this time, but that is not my decision.”