A "lethal mix" of failures at a Cumbrian hospital led to the unnecessary deaths of 11 babies and one mother, an investigation has ruled.
The inquiry into the University Hospitals of Morecambe Bay NHS Trust found 20 major failures from 2004 to 2013 at Furness General Hospital.
It called the avoidable incidents "serious and shocking".
And it criticised the wider NHS for the way it had monitored and regulated events at the hospital.
Health Secretary Jeremy Hunt said in the House of Commons that the tragedy was "a second Mid Staffs", albeit on a smaller scale.
Second Mid Staffs
In an echo of the inquiries in the Stafford Hospital scandal, the independent report said the problems found represented a "simultaneous failure of a great many systems at almost every level, from labour ward to the headquarters of national bodies".
Mr Hunt made number of recommendations, saying that the tragedy "must strengthen our resolve to deliver real and lasting culture change so these mistakes are never repeated."
He has appointed Dr Mike Durkin, National Director of Patient Safety at NHS England, to draw up new guidelines about reporting serious incidents as well as establish an independent national team that can go on rapid fact finding missions on a "no blames basis" as soon as issues arise.
And he's asked Prof Sir Bruce Keogh, Medical Director of NHS England, to review the professional codes of conduct for doctors and nurses to ensure mistakes are reported, not covered up.
The investigation - led by Dr Bill Kirkup, a former senior Department of Health official - found:
- The maternity unit had been "dysfunctional" with "substandard care" provided by staff "deficient in skills and knowledge"
- Working relationships between doctors and midwives had been extremely poor, with midwives referring to themselves as "the musketeers" as they pursued normal childbirth "at any cost"
- There had been "significant organisational failure" on the part of the Care Quality Commission.
- The North West Health Authority and Parliamentary and Health Services Ombudsman had failed to take opportunities that could have brought the problems to light sooner
- The Department of Health had been reliant on misleadingly optimistic assessments from regulators
Despite the failures starting in 2004 and continuing throughout the period, including a cluster of five major incidents in 2008, it was only in 2011 that the issues at Furness General came to wider attention.
This was after strong criticism from a coroner who looked into the death of newborn Joshua Titcombe. The coroner ruled Joshua had died of natural causes in 2008 but midwives had repeatedly missed opportunities to spot and treat a serious infection.
Around this time, a report came to light that the trust itself had commissioned. It was produced in early 2010 but "suppressed" by the trust.
But before that, the trust had failed to act on earlier incidents and even distorted the way information was presented to inquests.
Catalogue of errors
The CQC, regional health authority and ombudsman had not acted properly on what they knew either. There was knowledge of five major incidents in 2009 as the trust had revealed them as part of its application for foundation trust status, which is reserved for elite trusts.
But the regulators did not take the necessary action to fully investigate what had happened, and the trust gained foundation status in September 2010.
Dr Kirkup said: "This was a disturbing catalogue of missed opportunities."
His inquiry makes 44 recommendations, including:
- a national review of maternity care
- the General Medical Council and Nursing and Midwifery Council (NMC) to investigate the staff involved in care during the period
Six midwives are already due before the NMC later this year - and a seventh is being investigated.
Meanwhile, a police investigation into the death of Joshua Titcombe is continuing, and the Health and Safety Executive is looking into the case.
Pearse Butler, chair of the Morecambe Bay Trust, said: "The trust has made some very serious mistakes.
"More than that the same mistakes were repeated. For these reasons, on behalf of the trust, I apologise unreservedly to the families concerned. I am deeply sorry that so many people have suffered."
She said the trust would look to learn the lessons of what went wrong. She said there was a new leadership team in place and extra staff had already been taken on.
The parents' story
James Titcombe's son Joshua was nine days old when he died of sepsis. He was born at Furness General Hospital and was transferred to two other hospitals before dying in Newcastle.
"We asked repeatedly if Joshua should have antibiotics and we were told 'No, he didn't [need any]'," said Mr Titcombe.
"He was wheezing, and he wasn't feeding properly, and my wife called the emergency bell because he was grunting.
"And every time, we were told Joshua was fine and that there was nothing to worry about. At no stage was a doctor ever called."
Afterwards Joshua's progress chart went missing, never to re-emerge, and the coroner later said there was a suspicion that it may have been deliberately destroyed.
On the report's publication, Mr Titcombe said: "I think I feel deeply sad, angry as well, and vindicated, all at the same time.
"For me this report really lays out how preventable Joshua's death was. I really recognise now when we talk about missed opportunities in this report, that for me means not having a six-year-old."