1 Women referred by midwives to consultants for decisions on whether consultant-led care is advisable should be seen by consultants themselves and not by more junior members of their teams.

2 Doctors and midwives should record discussions with mothers - and the rationale for decisions about where they wish to have their baby - in the hand-held maternity records.

3 The performance of consultants and their teams and of midwives in providing care during pregnancy in the ante-natal clinic at Kidderminster needs to be more rigorously monitored as part of the trust's appraisal system.

4 The trust should develop a set of evidence-based guidelines on care of low-risk women during labour. The trust should have a programme of audit and training to support this.

5 The trust should ensure that there is a consensus between midwives and paediatricians and that guidelines are drawn up about the appropriate action to be taken, prior to transferring a baby that is in need of resuscitation to the consultant-led unit. The trust should have a programme of audit and training in these guidelines.

6 The trust should develop clear guidelines on the transfer of women and their babies to the consultant-led unit at Worcester. These should be agreed with the ambulance trust, and be supported by a programme of audit and training.

7 The trust should ensure that all its staff understand the correct procedures for registering deaths and provide written information for bereaved parents.

8 The trust should review arrangements to ensure that doctors and midwives maintain a professional standard of record keeping.

9 The trust should develop a clear protocol for providing information and support to parents when there have been adverse events.

10 The trust should develop guidelines on the conduct of internal investigations and reviews. These investigations should be overseen at board level. All health professionals involved in serious untoward incidents should be required to make signed written statements that are contemporaneous.

11 The trust should carry out a formal systematic review of the remedial or disciplinary action which is needed as a result of the findings of the investigations which have taken place. That review should be overseen at board level.

12 The trust should clarify responsibilities for clinical governance at all levels within the organisation.

13 The trust should review the effectiveness of the clinical governance structure and processes.

14 Development of clinical guidelines should involve all key groups and arrangements for audit and training should be put in place.

15 In order to make useful comparisons, the Department of Health should consider collecting data on maternity services in a way which makes it possible to identify the type of unit in which births take place.

16 The trust should review arrangements to obtain the views of users of maternity services to ensure that they are more meaningfully involved in the development of services. This should include greater input by senior clinical staff to relevant committees, support for PALS (Patient Advice and Liaison Services) at the Kidderminster site and routine user involvement in the development of guidelines.

17 The trust should consider the introduction of training for birth centre staff in communications and "customer care" to ensure that all staff have an awareness of the importance of this aspect of care to a woman's overall experience.

18 The trust should develop and introduce a policy of rotation of all its midwives between its maternity units.

19 Staff and trust grade obstetricians in the trust should have continuing professional development plans and these should be monitored as part of their annual appraisal.

20 The trust should strengthen the clinical leadership of maternity services in Kidderminster, and should consider creating a consultant midwife post to provide this. It should also ensure that there is clarity of and differentiation between the roles of all midwives.

21 The trust should review accountability arrangements for maternity services and ensure a clear reporting line between the chief executive and front-line clinical staff.

22 The trust should audit the care of low risk women who labour spontaneously at term across all the trust's maternity units to provide it with useful data with which to compare and monitor its service.

23 The PCT with the support of the SHA should develop a strategic vision to commission maternity services in Wyre Forest, either alone or in co-ordination with the other two PCTs in Worcester.

24 The PCT should monitor the performance of the trust in delivering maternity services and should routinely see the reports of untoward incidents in the trust.

25 The trust should bring forward proposals quickly to settle the future of the unit. Those proposals should reflect a vision for the provision of all maternity services for the residents of Wyre Forest.

26 If the birth centre is to reopen, a comprehensive action plan should be developed and implemented to address the recommendations in this report.

27 The DoH, RCOG and the RCM with other interested parties should develop operating standards for stand alone midwife-led maternity units (birth centres).