A leaked report has revealed a "toxic" culture at one NHS Trust, in which mothers and babies suffered avoidable deaths, in what's likely to be the NHS's worst-ever maternity scandal.
Children were also left with permanent disability amid substandard care at the Shrewsbury and Telford Hospital NHS Trust.
The interim update report, obtained by The Independent revealed staff routinely dismissed parents' concerns, were unkind, got deadbabies' names wrong and, in one instance, referred to a baby who died as"it".
One couple were denied the chance to say a final goodbye to their baby, after not being told the body had arrived back from a post-mortem examination. The remains had decomposed badly.
The report comes from an independent inquiry ordered by the Government in July 2017.
It's warned that lessons are still not being learnt in the present day - and that staff are still not communicating enough with families.
It refers 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.
Former Health Secretary Jeremy Hunt began the inquiry, which is being led by maternity expert Donna Ockenden. More than 270 cases from 1979 to the present day are being looked at.
They include: 22 stillbirths, three deaths during pregnancy, 17 deaths ofbabies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
Rhiannon Davies was one of the first to launch the campaign into the review. She lost her new born baby, Kate, in 2009 when she was only 6 hours old.
The interim report written by Ms Ockenden for NHS Improvement and the Trust highlights many cases of families suffering much pain around their experiences. They include:
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, leading to some children dying
Babies left brain-damaged from group B strep or meningitis that can often be treated by antibiotics
Many families "struggling" to get answers from the trust on "very serious clinical incidents" for many years and continuing to the present day
Families who told how "the trust made mistakes with their baby's name and on occasions referred to a deceased baby as 'it"'
Many families "where deceased babies are given the wrong names by the trust - frequently in writing"
One family 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
"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".
The Trust's slow response in sending the inquiry medical records, clinical notes and other documents was also criticised in the report.
Morecambe Bay, in which 11 babies and one mother died from avoidable circumstances at Cumbria's Furness General Hospital between 2004 and 2013, was until now the worst maternity scandal in the NHS' history.
The inquiry began after joint efforts from two families - 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.
An inquest ruled that baby Pippa could have survived if an infection had been spotted earlier.
“We have been working, and continue to work, with the independent review into our Maternity services. On behalf of the Trust, I apologise unreservedly to the families who have been affected. I would like to reassure all families using our Maternity services that we have not been waiting for Donna Ockenden’s final report before working to improve our services. A lot has already been done to address the issues raised by previous cases. Our focus is to make our maternity service the safest it can be. We still have further to go but are seeing some positive outcomes from the work we have done to date.