“A catalogue of tragedies” – that’s how the senior midwife Donna Ockenden described her review into maternity services at the Shrewsbury and Telford NHS Trust.
After a series of delays it was published today, and shows the scale of failings in what is now the worst maternity scandal this country has ever seen.
Her team looked at the cases of 1,500 families, and found hundreds of avoidable deaths of babies and mothers.
They found a toxic culture so pervasive that even in the last few weeks, staff have been coming forward to report their concerns about patient safety.
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