A damning report on a regional UK hospital system has found that around 131 stillbirths, 70 neonatal deaths and nine maternal deaths might have been avoided if better care had been provided.

Health Secretary Sajid Javid said the independent review, by Donna Ockenden, a midwife, revealed “a tragic and harrowing picture of repeated failures in care” between 2000 and 2019.

The report found that a lack of staffing, adequate training, effective investigations and governance at the Shrewsbury and Telford Hospital NHS Trust, and a culture of not listening to families, led to repeated failures in care. These included ineffective monitoring of foetal growth and a reluctance to perform caesarean sections.

There was a tendency to blame mothers for their poor outcomes — in some cases even for their own deaths. Many babies died during or shortly after birth, or suffered brain injury causing cerebral palsy, and women suffered lifelong physical and emotional effects. In one case, important clinical information was kept on post-it notes, which were swept into the bin by cleaners, with tragic consequences for a newborn baby and her family.

Ockenden told the media: “failures in care were repeated from one incident to the next. For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. In many cases, mother and babies were left with life-long conditions as a result of their care and treatment.”

She added: “A death of a mother or baby, or a birth incident which results in an injury should never be ignored. Thorough and timely expert investigations have to be undertaken which result in meaningful actions that improve quality of care, diagnosis and processes going forward. There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden.”