The Chairman of the Morecambe Bay Investigation, Dr Bill Kirkup, has said there was a "disturbing catalogue of missed opportunities" at Morecambe Bay NHS Foundation Trust.
He said had proper investigations into serious incidents been conducted as far back as 2004 it would have raised the alarm about the level of maternity and paediatric care being provided.
"There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health," Dr Kirkup said.
"Over the next three years, there were at least seven opportunities to intervene that were missed. The result was that no effective action was taken until the beginning of 2012."
Persistent failures at a maternity unit contributed to the unneccesary deaths of up to 30 infants and mothers, a report published today is expected to find.
The Morecambe Bay Investigation is set to claim that a "turf war" between midwives and doctors led to poor communications at the unit at Furness General Hospital in Barrow, Cumbria.
Health Secretary Jeremy Hunt, who ordered the inquiry, said at its launch in 2013 that the main aim was to uncover what went "desperately wrong" and ensure no repeat could take place.
Six midwives from Morecambe Bay NHS Foundation Trust, which runs the unit, are facing disciplinary hearings by the Nursing and Midwifery Council in the coming months.
In January 2014, one of the midwives received an 18-month interim suspensions following allegations over the care of a baby born in a "poor condition" the previous September.
Alice's mother Vicky will soon be reunited with the precious item, which bears her daughter's fingerprint, after a kind couple found it.Read the full story ›
Huge waves are crashing over the coastal wall in Whitehaven, Cumbria, as Britain braces for a so-called "weather bomb".
A 45-year-old man has been sent to prison for two years and eight months for deliberately infecting a woman with HIV.Read the full story ›
Mountain rescue volunteers wasted hours searching for a family who called for help, saying they were stuck at the peak of England's highest mountain - but who then climbed down unaided.
A man called Wasdale Mountain Rescue Team to ask for help, saying he, his wife and his son were trapped on Scafell Pike in the Lake District.
With weather conditions getting worse and the family not answering their phone, the rescue team began to comb the mountainside for the trio to bring them back down to safety.
Eventually, the family answered the phone at around 9.40pm - more than six hours after the first call - and told rescuers they had managed to climb down after all, and "didn't realise" they should notify the emergency services.
A spokeswoman for Cumbria Police urged walkers to only call for help if it is needed - and cancel it if it becomes no longer necessary.
By not informing us there is a drain on resources and potentially could hinder someone who does need urgent help. All we request is for people to be considerate.
A beleaguered health trust previously at the centre of a row over a high number of "serious untoward incidents" has been put into special measures.
The action has been taken against the University Hospitals of Morecambe Bay NHS Foundation Trust after inspectors from the Care Quality Commission (CQC) ruled the quality of care provided was "inadequate".
The trust runs Furness General Hospital in Barrow-in-Furness, Royal Lancaster Infirmary, Westmorland General Hospital in Kendal and Queen Victoria Hospital in Morecambe.
As part of the special measures, NHS regulator Monitor will appoint an improvement director whose role will be to provide support and expertise but also to hold the trust to account.
The wife of a soldier killed at an Army training base has paid tribute to him as her "soul mate" and "best friend".
Father-of-two Sergeant Mark Foley, 31, who served in Afghanistan, was killed in Warcop, Cumbria, while travelling in a military vehicle yesterday.
An investigation into the accident, which injured two other soldiers, is under way.
Paying tribute to her husband, who served with Norfolk-based The Light Dragoons, Kelly Foley said he was "the best dad ever" to daughters Emily and Hannah.
His commanding officer, Lieutenant Colonel James Senior, said: "Sergeant Foley was an exceptionally talented, battle-hardened soldier who embodied everything that is good about our profession.