More than 20 families have told BBC News they want a completely independent inquiry into maternity services at Nottingham University Hospitals (NUH) NHS Trust. We met some of those still shell-shocked by the trust's failings.
'Kaylan's heartbeat was dipping but they just left me'
The white walls of Hayley Coates' home are adorned with photos of her children.
They include some framed pictures of a newborn baby lying in an incubator, surrounded by tubes and wires.
That was Hayley's first child, Kaylan.
The 28-year-old mum from Broxtowe, in Nottinghamshire, says her first pregnancy was completely normal but everything went wrong during her long and difficult labour.
"I was pushing and pushing and nothing was happening. I kept saying the baby isn't coming and I need to go for a Caesarean, but staff kept saying I was going to have the baby naturally," says Hayley.
"I was on a drip for a very long time and Kaylan's heartbeat was dipping but they just left me."
When Kaylan was eventually delivered with forceps, his skull was fractured, he was starved of oxygen and he suffered major brain injuries.
He died in hospital from an infection a week later.
"My baby spent the majority of his short life just lying lifeless in an incubator with so many drugs pumped into him," says Hayley.
"The only time I got to hold Kaylan was when he had died.
"I didn't get to feel his warmth while he was alive, I didn't get to kiss his head. I didn't get to do anything."
Kaylan was born in 2018 at Queen's Medical Centre, one of two hospitals in the city run by NUH.
BBC News has seen the trust's serious incident investigation report following Kaylan's death, which states the care they gave to Hayley was in line with national guidelines.
But an inquest this year identified serious failings, with the coroner saying the care Hayley received was "nothing short of shocking" and Kaylan's death "could and should have been avoided".
"The trust wasn't open or honest with me. They just kept saying he died from an infection," says Hayley.
"Now I know his death should have been avoided and it makes losing Kaylan even worse.
"If it wasn't for their mistakes, he wouldn't have died.
"I lost my child and I went through so much pain and suffering which should never have happened.
"I don't know how I've got through the last few years.
"For a long time I couldn't leave the house, I just spent my days crying."
Hayley is now mum to four-month-old twin boys and a daughter, aged 16 months.
But she battles with PTSD and depression.
She is taking legal action against the trust and she backs plans for an independent inquiry where all the families who have been affected can be heard.
"Now that I've had more children I've got them to hold and cuddle, things I didn't have with Kaylan," she says.
"But the pain never goes away. When I'm looking at them, I think what would Kaylan look like, I imagine them all playing together. It's hard."
NUH said it could not comment on Hayley's case due to the ongoing legal action.
'There's a missing classroom of babies that should be alive'
There's a giant golden helium balloon with the number five on it floating in Jack and Sarah Hawkins' living room.
Every year they have a small celebration to mark their daughter Harriet's birthday - she would have been five this year.
Sarah had been in labour for six days before she gave birth to her stillborn daughter at Nottingham City Hospital in April 2016.
Harriet was delivered nine hours after dying.
"We knew as soon as they told us Harriet was dead, that something was wrong," says Sarah.
"I had been in labour for days. I wasn't listened to, I wasn't heard. I was made to feel like a total fraud."
"We raised concerns immediately. We were both senior clinicians at the trust at the time and we asked our friends and colleagues what was happening, why are babies dying? But no-one listened to us and it took years to find out the truth," says Jack.
After Harriet's death, an internal report by the trust, seen by BBC News, concluded the hospital had followed care guidelines and that there was "no obvious fault" by NUH.
But Jack and Sarah pushed for an external independent investigation which found 13 failings in care and concluded Harriet's death was "almost certainly preventable".
The investigation report said errors included important omission of information on an antenatal advice sheet, failure to take a full clinical history and a delay in applying appropriate foetal monitoring.
"They were not open or honest with us and I'm sure there are many other families who still don't know the truth because they didn't keep pushing for answers like we did," says Jack.
Jack and Sarah have not been able to work since losing Harriet.
They said their experiences have made it too difficult to return to the trust.
They are also taking legal action against NUH.
They want an independent inquiry into the trust's maternity services because they believe there will be many other families who need answers.
"We know there will more than a missing classroom of babies that should be alive," says Jack.
"We deserve a completely independent public inquiry going back at least a decade. Everyone needs answers and we need to stop it from happening again."
'The doctors cut out my bladder without realising'
Felicity Benyon, from Mansfield in Nottinghamshire, faced lifelong injuries after she gave birth to her second child.
"My pregnancy was really tough. I had unexplained bleeding for most of it and I was in hospital for almost five months," says Felicity.
Felicity says the doctors suspected she had a potentially fatal pregnancy complication called placenta percreta, where the placenta attaches itself and grows through the uterus.
During her planned C-section it was confirmed she needed to have an emergency hysterectomy.
"I lost four litres of blood and I nearly lost my life," says Felicity.
"The hysterectomy went really wrong because when the doctors took my womb out, they also cut my bladder out without realising it."
The 35-year-old mum to two children, aged 10 and five, now has to live with a urostomy bag for the rest of her life.
Felicity hired a legal team and, as a result of their investigations, she believes the hospital did not have the right team of specialists on hand during the C-section.
She said there should have been a multidisciplinary team of specialists on standby during the C-section, given they suspected she had placenta percreta.
"When they started the operation and realised it was percreta, the doctors didn't have the right experience to deal with it," she says.
"I shouldn't have lost my bladder, there was nothing wrong with it. That's really the hardest thing to live with."
Felicity didn't think the trust investigated the incident properly so she turned to a lawyer.
''I went down the legal route to prevent this from happening to anyone else," she says.
"I didn't think the trust was open or honest about what had gone wrong.''
Felicity reached a settlement last year with the trust, which accepted liability, but she says nothing can make up for the pain and trauma she has had to deal with.
"Having a urostomy bag impacts my life every single day," she says.
"I have to make sure I empty it before I go on the school run, I need to drink enough water to avoid an infection.
"The older I get, the greater the risk of complications and more surgeries.
"This could have all been prevented."
NUH chief nurse Michelle Rhodes said: "We sincerely apologise to Ms Benyon for the harm that was caused during this complex surgery. The incident was thoroughly investigated and we have discussed the findings with Ms Benyon."
How bad are things at the trust?
An investigation by Channel 4 News and the Independent reported 46 babies had suffered brain damage and 19 were stillborn in Nottingham in recent years.
The BBC has found there have been at least seven preventable deaths of babies between 2015 and 2020.
Both maternity services run by NUH are rated as inadequate by the Care Quality Commission (CQC).
Through a freedom of information probe, BBC News has learned there have been 34 maternity investigations following adverse incidents at NUH since 2018.
They have involved:
- Three maternal deaths
- 22 babies who faced potential severe brain injury
- Four neonatal deaths
- Five stillbirths
The Healthcare Safety Investigation Branch (HSIB) has identified numerous deficiencies in care and made 74 recommendations to NUH across all the cases they investigated.
The trust was identified as an "outlier" in relation to the incidence of neonatal deaths, stillbirths and the number of babies requiring cooling following birth by HSIB, according to the CQC inspection in 2020. The regulator also found "little evidence" the HSIB recommendations were being acted upon.
Tracy Taylor, NUH chief executive, says: "We apologise from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognise the effects have been devastating.
"Improving maternity services is a top priority and we are making significant changes."
This month, the government announced plans for a review of maternity services were being drawn up.
However, families claim the review is not independent enough, there has not been enough input from families and doesn't look back far enough.
Mr Hawkins said: "We know that what is needed is a truly independent review. Not one where it will be too easy to suggest NUH have had a hand in it, where parents of dead and damaged babies are ignored and excluded from the process of deciding what needs looking at.
"We are pretty sure we will get the appropriate independent inquiry and are saddened that, yet again, families in Nottingham are having to fight to be heard and involved, rather than being welcomed and cherished."