An initial review into baby deaths at Shrewsbury and Telford NHS Trust has identified seven "immediate and essential actions" needed to improve maternity care in England and 27 local actions for learning.
Review chair, senior midwife Donna Ockenden, made the recommendations after finding repeated failures at the trust including a lack of compassion by some maternity staff and concerns about care by families being "dismissed".
It concluded there are seven immediate and essential actions for maternity services across England:
The report stated the importance of increased partnership between Trusts, recommending that Trusts work together to investigate serious incidents and ensuring learning is shared regionally in a timely manner.
Listening to women and families
Every Trust must create a senior advocate role which will represent women and family voices to the Trust’s board, the report said.
All Trusts must ensure they have a non-executive director on the board with specific responsibility for ensuring women and family voices are represented at board level.
Staff training and working together
Staff training must be multidisciplinary and include all maternity team members, it was recommended.
There must be twice daily consultant-led ward rounds, seven days a week, during the day and at night.
Trusts must ensure that any externally allocated training funds, which have been provided for maternity services, must be ring-fenced for their intended purpose.
Managing complex pregnancy
The development of maternal medicine specialist centres within regions must be an urgent national priority, the report said.
There must be early involvement of and discussion with specialist centres for women with complex medical issues, it added.
Risk assessment throughout pregnancy
The report said that all women must be formally risk assessed at every antenatal contact, so they have access to care from the most appropriately trained professional in the most appropriate setting for their individual needs.
Monitoring foetal wellbeing
All maternity services must appoint a dedicated lead midwife and lead obstetrician with expertise in the field of foetal monitoring in order to improve upon practice in foetal monitoring.
The Ockenden Review also said 27 recommendations should be implemented at the Shrewsbury and Telford NHS Trust, including:
Greater consultant oversight of maternity care;
The appointment of lead obstetricians and midwives with expertise in foetal monitoring and bereavement care to lead on significant improvements;
Multidisciplinary training and working;
Ongoing risk assessment for all women;
Enhanced multidisciplinary and family input into serious incident investigations; and
Greater involvement from obstetric anaesthetists when women have complex needs or become ill.