Babies and mothers died during major failings at a hospital trust, in what is likely to be the worst ever NHS maternity scandal.
A "toxic" culture was in place at Shrewsbury and Telford Hospital NHS Trust stretching back 40 years when babies and mothers suffered avoidable death, according to a report leaked to The Independent.
It found staff at the trust routinely dismissed parents' concerns, were unkind, got dead babies' names wrong and in one instance referred to a baby who died as "it".
In another case, parents were not told their baby's body had arrived back from the post-mortem and the body was left to decompose so badly that the family never got to say a final goodbye.
Children were also left with permanent disability while there was substandard care at the hospital.
A mother whose baby died shortly after birth at the trust in 2009 has now called for a corporate manslaughter charge to be brought.
The interim update report – which has also been seen by the Press Association news agency – comes from an independent inquiry ordered by the government in July 2017.
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Cases being examined include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
The report warns that, even to the present day, lessons are not being learned and staff at the trust are uncommunicative with families.
It also points to an inadequate review carried out by the Royal College of Obstetricians and Gynaecologists (RCOG) in 2017, and the "misplaced" optimism of the regulator in charge in 2007.
Until now, Morecambe Bay, which saw the avoidable deaths of 11 babies and one mother at Cumbria's Furness General Hospital between 2004 and 2013, was the worst ever maternity scandal in the history of the NHS.
Maternity expert Donna Ockenden is leading the inquiry into Shrewsbury and Telford Hospital NHS Trust.
The inquiry's initial scope was to examine 23 cases but this has now grown to more than 270 covering the period 1979 to the present day.
The interim report, written by Ms Ockenden for NHS Improvement and the trust, details the pain suffered by the families.
It points to:
:: Babies left brain-damaged because staff failed to realise or act upon signs that labour was going wrong
:: A failure to adequately monitor heartbeats during labour or assess risks during pregnancy, resulting in the deaths of some children
:: Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics
:: A baby whose death from group B strep could have been prevented after its parents contacted the trust on several occasions worried about their newborn
:: Many families "struggling" to get answers from the trust around "very serious clinical incidents" for many years and continuing to the present day
:: One father whose only feedback following his daughter's death was when he bumped into a hospital employee in Asda
:: One parent reporting a "closed culture" at the trust over hospital fears of being sued
:: Families who told how "the trust made mistakes with their baby's name and on occasions referred to a deceased baby as 'it'"
:: Multiple families "where deceased babies are given the wrong names by the trust – frequently in writing"
:: One family who was told they would have to leave if they did not "keep the noise down" when they were upset following the death of their baby
:: One baby girl's shawl was lost by staff after her death even though her mother had wanted to bury her in it
:: The "misplaced" optimism of the regulator the Healthcare Commission (a predecessor to the Care Quality Commission) that maternity services would improve following its interjection in 2007
:: Families who were advised "they were the only family", and that "lessons would be learned". The report said "it is clear this is not correct"
:: A "long-term failure" to involve families in serious incident investigations, some of which were "overly defensive of staff"
The inquiry was launched following the efforts of Rhiannon and Richard Stanton Davies, whose daughter Kate died shortly after birth in 2009, and Kayleigh and Colin Griffiths, whose daughter Pippa died shortly after birth in 2016.
Ms Davies, from Hereford, said she was "going to push for the police to bring a charge of corporate manslaughter against the trust".
She added: "The narrative that lessons have been learned has to change because lessons are not being learned.
"Everything within that (the leaked report) happened to us."
Sharon Morris, who gave birth to twins 14 years ago, said her daughter was left with a brain injury after hospital staff failed to notice she was in distress because they were monitoring the wrong heartbeat.
She said: "My daughter was starved of oxygen during this time and is now severely disabled needing 24-hour care, can't eat, can't Read More – Source