It was created with the very best of intentions – to help hospitals learn lessons when a baby or mother is harmed or dies.
But our investigation has been hearing that the maternity programme of the Healthcare Safety Investigation Branch – or HSIB – was riddled with flaws.
One former senior staff member has told us about bullying within the organisation and failings which could have led to harm.
In a previous report, we heard from the mothers of Beatrice and Marnie, who were stillborn and tonight other parents have come forward with their experience.
Warning: You may find details and images of this report distressing from the very start.