When Baroness Amos was appointed to lead the National Maternity and Neonatal Investigation, I said something that wasn't universally popular among bereaved families. I said we had to give the process a chance.
We had to allow someone with fresh eyes the opportunity to look across the whole system and tell us what she found.
No bereaved family will ever be 100% happy with any report or any set of recommendations. That is simply impossible. When your child dies, when your wife dies, when your baby suffers lifelong injury, no report can ever undo that. No recommendation can soothe that existential grief.
We carry the imprint of our worst fears for the rest of our lives, embedded in every cell of our being.
So, success was never going to be measured by whether every family agreed with every word. It had to be measured against the remit Baroness Amos was actually given.
On that test, I believe the report broadly succeeds.
It’s a weighty piece of work. It draws together themes that families have been describing for decades and, crucially, reinforces a truth many of us have reached ourselves: we already know what’s going wrong.
The challenge is no longer identifying failings. It's implementing lasting change.
For me, that is the most important message to emerge from this report.
Because the defining failure in maternity care has never simply been that mistakes happen. Mistakes will happen in every healthcare system. The real tragedy is that the same mistakes happen again and again, despite inquiry after inquiry, report after report, and family after family describing the same failures.
Knowing what needs to change is no longer the problem. Finding the will, the leadership and the accountability to make that change endure is.
Again and again we have failed to act.
We have failed to act when a woman says something is wrong.
We have failed to act when labour deviates from the normal pattern.
We have failed to act when warning signs are present across multiple clinicians, multiple appointments and multiple records but are never brought together.
We have failed to act when investigations identify lessons.
We have failed to act when accountability is needed.
And ultimately, we have failed to act after every major inquiry before this one.
If nothing else is remembered from Baroness Amos's report, I hope that lesson is.
One area where I think the report is particularly strong is that it reframes listening to women as a patient safety issue rather than simply an issue of patient experience.
That distinction matters enormously.
For years we've heard the phrase "women weren't listened to." It almost sounds passive, as though this is about courtesy or bedside manner.
It isn't.
What families are actually describing is that critical warning signs were missed.
Signals weren't recognised. Patterns weren't connected. Clinical concerns weren't recorded properly. Escalation didn't happen.
Listening is not about making women feel heard for the sake of it. Listening is about recognising safety-critical information that could prevent harm or save lives.
That is a fundamental shift in thinking, and one I wholeheartedly welcome. That alone would have saved Kate.
The report also places considerable emphasis on maternity triage.
Again, I think this has huge potential, but only if we get it right. The NHS has become burdened by layers of ageing IT systems, duplicated documentation and technology that has been hacked together over decades. If maternity triage simply becomes another cumbersome form for exhausted clinicians to complete, we will have missed the point entirely.
But if it is designed from the ground up - with clinicians involved, digital systems that actually talk to each other, and the right staffing and infrastructure behind it - it could be transformational.
We don't need to invent excellence. Let's find the best-performing A&E department in the country. Study how their triage systems identify deterioration, prioritise risk and support clinical judgement. Learn from them. Adapt it properly for maternity rather than creating another standalone process in isolation.
This is exactly where the next phase of work matters. Baroness Amos was never expected to solve every operational challenge herself. She was tasked with identifying the themes.
The National Maternity and Neonatal Taskforce must now do the harder work of turning those themes into practical, workable change. That is what many of us understood the process would be.
Those calling for a Public Inquiry will undoubtedly continue to do so. Ironically, Kayleigh, Colin, Richard and I were calling for one before many of today's voices had entered this debate. Alongside 37,000 of you who signed our petition, we argued for a UK-wide inquiry across England, Scotland, Wales and Northern Ireland because we could already see the same themes emerging everywhere, with no real will to deliver the change that was needed.
Instead, Wes Streeting chose a different route. In one meeting he addressed me directly and asked: "…are there areas for rapid improvement?"
My answer was yes.
Based on the research Kayleigh and I had undertaken across all four nations, there absolutely were. And that is why, in part, this investigation exists. It was never designed to replace every function of a Public Inquiry. It was designed to identify where rapid improvements could save lives while also setting out the systemic reforms needed for the future.
Where I do think the report falls short is in its failure to grapple properly with the continuing influence of natural birth ideology within maternity care.
This is not a peripheral issue. It continues to shape decision-making, attitudes towards intervention and, in some cases, the willingness to recognise when birth is no longer progressing safely.
Bill Kirkup resigned from the investigation over this issue. That alone should prompt serious reflection. Because if we cannot honestly confront the cultural drivers that continue to influence clinical decision-making, we risk leaving one of the deepest causes of avoidable harm untouched.
Finally, accountability.
The report is right to say our current system often leaves families searching endlessly for answers while frontline staff become convenient scapegoats. That serves nobody. Real accountability isn't about blame. It's about creating organisations capable of recognising failure, understanding why it happened, learning openly, supporting improvement and ensuring the same mistakes cannot happen again.
Too often, board-level accountability disappears entirely while individuals lower down the hierarchy carry the consequences. The result is a culture of fear, defensiveness and inertia, where meaningful change becomes almost impossible. That benefits no one - not patients, not staff and certainly not bereaved families.
Families deserve better. Staff deserve better. Women and babies deserve better.
Baroness Amos has identified many of the right problems. Now comes the part that has defeated every review before this one.
Implementation.
Because history tells us that writing recommendations is the easy part. Having the courage to implement them is what will determine whether lives are saved - or lost.