The Ockenden report confirms there were decades of poor treatment, failures to learn and widespread culture of disregard for the concerns of parents in Shropshire who were simply seeking safe care.
It fell upon the current Health Secretary and Bromsgrove MP Sajid Javid to make today's statement to the Commons.
In one especially shocking section he detailed how vital notes about a newborn's clinical needs had been written on Post-it notes - later swept away by cleaners.
He had been told of the tragic consequences by report author Donna Ockenden.
Sajid Javid says Donna Ockenden told him about one case where important clinical information was kept on post-it notes - which were swept into the bin by cleaners
Sajid Javid made a formal apology to the families affected by the scandal saying, "To all the families that have suffered so gravely, I am sorry."
He also gave details of how those responsible for the "serious and repeated failures" will be held to account.
A number of people working at the trust at the time have been suspended or struck off from the professional register and members of senior managers removed from post
But perhaps most significantly he committed to enacting every single one of the recommendations made in today's report at both local and national level.
There are 66 actions ordered for the local trust, 15 for the wider NHS and 3 for the Secretary of State. He said "we will make the changes".
Later he acknowledged- in answer to a question from the Telford MP Lucy Allan - that "time and time again" it was "women's voices" that have been consistently ignored. He said that it was vital to change that culture.
'Women's voices were not heard'
It will not have been easy to outline the huge and shocking scale of the maternity scandal that has harmed so many.
Mr Javid hopes the pledge of £127m to begin putting things right will be of some comfort and reassurance - but he also knows that the need for a comprehensive change in culture in maternity care can no longer be silenced.
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