The National Maternity and Neonatal Investigation, external was set up last summer by the then-health secretary, Wes Streeting.

The 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.

Baroness Amos and her team heard from more than 450 families and visited 12 NHS trusts to understand what change was needed.

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.

The system is “fragmented, overly complex and too slow to learn and improve,” Baroness Amos noted in her report.

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”.

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”.

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.

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.

“Statutory public inquiries take a very, very long time,” she told the BBC.

“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.”