Mothers and babies suffered avoidable death due to major failings stretching back 40 years at an NHS trust, according to a leaked report.
In what is likely to be the NHS’ worst ever maternity scandal, the report showed a “toxic” culture at Shrewsbury and Telford Hospital.
Staff at the trust routinely dismissed parents' concerns, were unkind, got the names wrong of babies who had died and, in one instance, referred to an infant as “it”.
In another case, parents were not told their baby's body had arrived back from the post-mortem examination, and it was left to decompose so badly that the family never got to say a final goodbye.
The substandard care also left children with permanent disability – some babies suffered brain-damage because staff failed to realise or act upon signs that labour was going wrong.
The interim update report comes from an independent inquiry ordered by the government in July 2017 and warns that, even to the present day, lessons are not being learned.
It said staff do not communicate effectively with families and many families are still “struggling” to get answers.
The inquiry, which was launched by the then health secretary Jeremy Hunt, is being carried out by maternity expert Donna Ockenden.
Ms Ockenden said the interim report was produced at the request of NHS Improvement and not meant for publication.
In it she wrote: “No apology will be sufficient or adequate for families who lost loved ones to avoidable deaths, or whose experience of becoming a parent was blighted by poor care and avoidable harm.
“Many families have described to me how they live on a daily basis with the results of that poor care.”
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