The concerns of families affected by maternity failures in Nottingham should have been acted on sooner, senior midwife Donna Ockenden has said.
Her comments come as police announced a criminal investigation into the failings at Nottingham hospitals.
Ms Ockenden, who is leading the largest review into failings in maternity care in NHS history at the Nottingham University Hospitals NHS Trust (NUHT), said "families were not listened to".
Her investigation will involve around 1,800 families and look into the deaths of several babies and the harming of babies and mothers at its three sites in the city.
When asked if concerns should have been acted on earlier, she said: "Absolutely. On Wednesday, the families released to the public copies of letters where they were raising very significant concerns about the safety of maternity in Nottingham from April 2016."
"These included letters to the board, to the coroner, to the wider NHS system and they were not listened to."
One bereaved couple have revealed that they shared fears of a cover-up seven years ago.
Dr Jack and Sarah Hawkins both worked at NUHT and were one of the first families to raise concerns over care failings after the death of their daughter Harriet during labour on 17 April 2016.
Letters the couple wrote to the NUH board on 2 June 2016 show they formally raised their worries about the care they received during Harriet’s birth.
They wrote: “We are not sure what is happening, but are deeply concerned that the plan is for an internal investigation performed by the obstetric team, without our involvement, followed by a meeting with a consultant. This is neither appropriate nor proportionate.
“We need to trust that NUH are conducting an appropriate inquiry. We do not currently believe that you are. Can you re-assure us please?”
Also speaking on the Today programme on Friday, Dr Hawkins said: “We realised as soon as we were told ‘I’m sorry your baby is dead’ that something had gone wrong.
“We told them in 2016 that their view on maternity safety was so poor that there could be someone causing deliberate harm and that is documented and written to all the right people and ignored.”
"There is a duty to be honest and open"
Ms Ockenden told the Today programme that the professional duty of candour, which requires every health and care professional to be open and honest with patients when something that goes wrong with their treatment or care causes or has the potential to cause harm or distress, was not being “properly applied”.
She said: “There is a duty to be honest and open and we will need to look at everything that comes out.
“Very, very serious concerns were raised in the months after Harriet died and nothing material was done. They were not listened to.”
She said she is confident the police investigation and her own independent review can go ahead without obstructing each other.
Ms Ockenden said: “I had an in-depth conversation with (Chief Constable at Nottinghamshire Police) Kate Meynell on Wednesday. She has assured me the work of her officers will not impede our progress.
“It will be like two trains going along parallel lines. We will of course co-operate with their investigation but I’m not anticipating their work will delay ours.”
Anthony May, who inherited the scandal when he became the trust’s chief executive last year, is supportive of Ms Ockenden’s review and will also co-operate with the police probe.
Want a quick and expert briefing on the biggest news stories? Listen to our latest podcasts to find out What You Need To Know...