Maternity services should regularly report safety data to improve the safety of maternity care.[4] Although some progress has been made in recent years in improving outcomes and staffing of maternity services, the national maternal and newborn care system remains overly complex and uncoordinated.[4] A significant problem is that there are too many recommendations for improvement with limited implementation and that services still lack a consistent ability to identify and respond to clinical risks.[4] Cooperation and information sharing between national organizations is inconsistent and variable, which prevents learning from mistakes and harms that happen to women and children during pregnancy, labor and delivery.[4] The government announced a fast-track national inquiry into maternal and newborn safety, with the aim of completing it by December 2025, and created a new commission on maternal and newborn safety.[5] To be effective, these measures must be based on in-depth analysis, independence and genuine listening to families affected by security failures.[5]