The death of a premature baby in 2001 led to a “20-year cover-up” of mistakes by health workers, an independent inquiry has found.
Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday.
The government, which ordered the inquiry in 2017, said the mistakes in her care were “shocking and harrowing”.
The inquiry report by Dr Bill Kirkup said some of those involved had been “persistently dishonest”.
Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home.
Dr Bill Kirkup was appointed by the government to review events since her birth at Frimley Park Hospital in Surrey in December 2000.
Publishing the report, health minister Nadine Dorries said it described a “harrowing and shocking series of mistakes associated with the care received by Elizabeth and a response to her death that was completely inadequate and at times inhumane”.
She added: “The investigation sheds light on what the report describes as a ’20-year cover-up’. It alleges that some individuals have been persistently dishonest in accounting for their actions or inaction.”
Ms Dorries said the baby’s parents, Anne and Graeme Dixon, from Church Crookham, were let down by failures to diagnose their daughter’s underlying condition and to put in place adequate care.
She said: “This report shines a light on a culture of denial and cover-up 20 years ago.”
The minister said the report concluded that “conscious choices to cover up or to be dishonest should not be tolerated”.
Ms Dorries said she was sorry for the devastating impact of the baby’s death on her parents and paid tribute to them for their long campaign for justice.
By Michael Buchanan, BBC News social affairs correspondent
The inquiry’s findings, released earlier, mark the latest stage in a remarkable, determined two-decade campaign by Elizabeth’s parents, Anne and Graeme Dixon, to uncover failings by the NHS, the police and other institutions.
“The whole thing has taken over too much of our lives,” says Graeme, 62, an electronics engineer.
Anne, 57, says the sight of a police car, or an image on the television, can bring the bad memories flooding back.
“We think about it every day,” she adds.
The results of the inquiry are a major step forward for the family, but their campaign to ensure there is nationwide learning from Elizabeth’s care will continue despite the personal toll its taken.