Mothers were blamed for their babies’ deaths and a large number of women died in labour at scandal-hit maternity unit, a review has found.
The inquiry into Shrewsbury and Telford Hospital NHS (SaTH) trust found deaths were often not investigated and an induction drug was repeatedly misused.
It is looking into 1,862 cases, the vast majority from 2000 onwards.
The review – the largest ever of NHS maternity care – lists 27 actions the trust must immediately carry out.
It began in 2018 following campaigns led by two families. Richard Stanton and Rhiannon Davies’ daughter Kate died hours after her birth in March 2009, while Kayleigh and Colin Griffiths’ daughter Pippa died from a Group B Streptococcus infection.
In June police launched an investigation to examine if there was evidence to support a criminal case against the trust or any individuals involved.
The review, led by senior midwife Donna Ockenden, has initially examined 250 cases and made seven “immediate and essential” actions for all maternity services across England.
It found letters and records “which often focused on blaming the mothers” rather than considering whether the trust’s systems were at fault. This was exacerbated by the attitude of staff, the report said.
It said: “One of the most disappointing and deeply worrying themes that has emerged is the reported lack of kindness and compassion from some members of the maternity team.”
“The fact that this was found to be lacking… is unacceptable and deeply concerning.”
Ms Davies’ daughter Kate was born “pale and floppy” at Ludlow Community Hospital and died after delays in transferring her from Ludlow to a doctor-led maternity unit.
She has fought for a review for 11 years and said: “I may sound arrogant but I’ve never doubted my surety of what happened with Kate.
“I knew I was right. The interim findings will hopefully bring this essential change, critically required change, change this trust has not been able to see it needs to embed and that will hopefully ensure patient safety improves and that is the only reason we’ve continued.”
Ms Ockenden said the first review and the work that follows “owes its origins to Kate Stanton-Davies and her parents”.
She added Kate and Pippa’s parents have shown “an unrelenting commitment in ensuring their daughter’s short lives made a difference to the safety of maternity care”.