, external<\/span><\/a> was set up last summer by the then-health secretary, Wes Streeting.<\/p>\nThe aim to was produce a report to drive through improvements across England after a series of maternity scandals undermined the trust of many families in the NHS.<\/p>\n
Baroness Amos and her team heard from more than 450 families and visited 12 NHS trusts to understand what change was needed.<\/p>\n
The key failing they identified was an unwillingness to listen to women and families, leading to poor outcomes. There was a lack of a consistent standard of care, with large variations across the health service.<\/p>\n
The system is “fragmented, overly complex and too slow to learn and improve,” Baroness Amos noted in her report.<\/p>\n
One of the immediate actions being urged on maternity units is to overhaul their triage service, which Baroness Amos described as “increasingly becoming the A&E service for maternity”.<\/p>\n
As part of that, midwives should be dedicated to answering calls and providing timely advice, while 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”.<\/p>\n
Meanwhile, racism and discrimination must be treated as a critical safety issue, the inquiry found, requiring urgent intervention including gathering granular data on unequal outcomes that is escalated to board level when patterns emerge.<\/p>\n
Baroness Amos acknowledged calls for a statutory public inquiry that would compel senior figures at under-fire hospital trusts to give evidence. But she is not supportive of such a move.<\/p>\n
“Statutory public inquiries take a very, very long time,” she told the BBC.<\/p>\n
“From the work that I have done and from the conversations that I have had with families, I don’t at the moment see that there is a need for a statutory public inquiry, but that’s not a decision for me to take.”<\/p>\n<\/div>\n
\n
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