Seven babies and three mums have died in two Greater Manchester maternity units in the space of just eight months – sparking an independent investigation.
Bosses at Royal Oldham and North Manchester General Hospital called in outside experts to review the departments in light of the 10 tragedies.
It is understood the deaths took place between December 2013 and July last year – with four babies and two mums dying at Oldham, and three babies and one mother dying at North Manchester.
An investigation by the Manchester Evening News revealed that the Pennine Acute Trust, which manages both hospitals, commissioned the external review in July last year and received the findings back at the start of this year.
A summary of the review, pointed towards several points of failure including 'below standard risk management' during labour, an 'absence of clinical leadership' and a mismanagement of the risk posed by three of the women being obese or morbidly obese.
Although the review did also point out that the maternal deaths did not appear to be the result of 'deficiencies in care'.
The families of the babies and mothers were not told about the external review until the Manchester Evening News approached Pennine Acute Trust about it.
Martin Beaty, whose newborn baby Thomas died at Royal Oldham in April Last after a repeated failed forceps delivery told the paper she was not surprised at the high number of deaths.
Thomas Beaty suffered devastating head injuries at Royal Oldham Hospital as doctors pushed him back into the womb after failing to pull him out with forceps five times. National guidelines recommend three attempts.
Pennine Acute is in the process of producing an action plan based on the recommendations from the findings.
They include strengthening clinical leadership and risk management, making sure enough staff are on duty to ensure safety and reviewing the process for employing temporary locum doctors.
Royal Oldham Hospital’s new maternity unit, children’s unit and neonatal intensive care unit opened in December 2012. The £44M facility became one of three specialist Greater Manchester neonatal centres, providing intensive care to vulnerable babies, as part of a controversial £120M shake-up which saw maternity units shut in Bury, Rochdale and Salford.