More than 200 babies suffered avoidable deaths over two decades at a UK maternity hospital, a review has found.
The investigation has revealed persistent failures at the Shrewsbury and Telford NHS Trust in western England.
Up to 131 stillbirths, 70 neonatal deaths and nine maternal deaths either could have or would have been avoided with better care, the report found.
The review began in 2018 after two families that had lost their babies at the maternity hospital campaigned for an inquiry.
Former senior midwife Donna Ockenden led an investigation into nearly 1,600 incidents between 2000 and 2019, including cases of stillbirth, neonatal death, and maternal deaths.
The 250-page report also looked into cases of newborns with fractured skulls, broken bones and brain problems after lack of oxygen at the time of birth
Ockenden said Wednesday that the hospital's management “failed to investigate, failed to learn and failed to improve.”
“This resulted in tragedies and life-changing incidents for so many of our families,” she said.
Ockenden’s initial report in 2020 found that a pattern of failures and poor maternal care led to avoidable deaths and harm to mothers and newborns. Deaths were often not investigated and grieving mothers were at times blamed for their loss, she found.
Ockenden said the hospital had focused on keeping cesarean section rates low but that in some cases opting to perform C-sections earlier would have avoided death and injury.
The former midwife said on Wednesday that she was “deeply concerned” that families had continued to contact the investigators in 2020 and 2021 with concerns about the safety of care at the hospital.
Ockenden said there had been some progress since her 2020 report but “systemic” improvement was needed across the country, including ensuring maternity units were properly staffed and funded.
Shrewsbury and Telford NHS Trust chief executive Louise Barnett offered “wholehearted apologies.”
"We owe it to those families we failed and those we care for today and in the future to continue to make improvements,” Barnett said.
UK Health Secretary also issued an apology in parliament on Wednesday.
"To all the families who have suffered so much, I am sorry," Javid told MPs. "You have been let down by a service that was there to help you and your loved ones give life."