The lack of progress following the Morecambe Bay inquiry into the deaths of 11 babies and a mother in a maternity unit risks "another avoidable disaster", the chair of the inquiry has said.
The investigation into the deaths at Furness General Hospital uncovered a "lethal mix" of failures between 2004 and 2013. Led by Dr Bill Kirkup, a former senior Department of Health official, the inquiry found "failings at almost every level, from labour ward to the headquarters of national bodies".
The "dysfunctional" maternity unit gave "substandard care", with staff "deficient in skills and knowledge", it said.
Now Dr Kirkup has said that there has been "no visible action" in some key areas highlighted in his report which was published a year ago.
In an interview with the Health Service Journal (HSJ), Dr Kirkup said that there had been progress on only 10 of the 26 national recommendations made in the report.
Dr Kirkup told the HSJ: "There has been no visible action in some key areas and I don't think that is appropriate.
"Given that we are a year on, it is a disappointing position overall. I think now would be a very good time to take stock publicly and say this is what we have been able to do, this is what we are still to do and this is what we are not going to do."
He added: "Just ignoring the problem is not an option. It leaves us in the dark."
Dr Kirkup continued: "I think a lot of this is about inertia and the difficulty in managing a very complicated system where you have complex sets of organisations and arrangements. I am also very mindful of the fact that people's attention is massively consumed by trying to keep afloat, never more so than at the minute, in the midst of winter pressures, with delayed transfers of care and funding that is limited.
"But we ought to be able to focus on more than one problem at a time. I do know that it is difficult but if we don't do that the worst possible outcome is that we replicate the same mistakes somewhere else and produce another avoidable disaster."
James Titcombe, whose son Joshua died after failings at Morecambe Bay, told the HSJ: "I share the deep frustration and dismay about the lack of progress over the past year.
"I am especially disappointed in the failure of the NMC (the Nursing and Midwifery Council) and GMC (the General Medical Council) as well as the Trust to hold anyone accountable almost seven years after Joshua died.
"It is really important that over the next six months, substantial progress is made."
A spokeswoman for NHS England said: "The widely welcomed independent National Maternity Review sets out comprehensive proposals designed to make care safer, give women greater control, encourage multi-professional working, and ensure flexibility for remote and rural areas - all key lessons from Morecambe Bay.
"It also drew on the best UK and international evidence of safety in maternity care produced by Oxford University's National Perinatal Epidemiology unit."
A Department of Health spokeswoman added: "Our NHS remains one of the safest places in the world to give birth and we are absolutely committed to improving maternity care.
"Since the tragic events at Morecambe Bay, we have committed to strengthening supervision of midwives, increasing the protection for whistleblowers and introduced complaints handling as a crucial element of our tougher hospital inspection regime.
"We are setting up a new Healthcare Safety Investigation Branch which will deliver timely and high quality investigations into serious incidents, helping improve investigation practice and capability in the NHS by acting as an exemplar."