The Ockenden Inquiry into maternity care at Shrewsbury & Telford NHS Trust has found that hundreds of families were failed in its care.
The review has found more than 200 cases where mothers died, where babies were stillborn, or there was neonatal death, had significant or major concerns – and where different care would have resulted in a different outcome.
Another 106 cases involving cerebral palsy and brain damage were found to have the same concern. With better care likely to have led to a better outcome.
The review, which includes cases as early as 1973 and as recent as 2020 - but mainly covered the period from 2000 to 2019 - has outlined 60 actions needed to be taken by the trust to improve its care.
There are also 15 recommendations for maternity across the country.
The report lists poor investigations, midwives who were fearful of superiors over the escalation of cases, staff who were over confident and a unit at Royal Shrewsbury Hospital 'operating beyond its scope'.
The trust was found to failed to follow national guidelines in a number of areas: fetal heart rate monitoring; maternal blood pressure; management of gestational diabetes; and resuscitation.
The review details a 'them and us' culture between midwifery and obstetric staff with 'poor working relationships also witnessed by families'.
The report also details a lack of compassion from staff.
It states: "Repeatedly throughout this review we have heard from parents about lack of compassion expressed by staff either while they were still receiving care or in follow up appointments and during complaints processes.
"Examples include clinicians being unprepared for follow up briefings with families, and response letters to complaints containing inaccurate information, justifying actions or omissions in care and in some cases even including explanations which laid blame on the family themselves for the particular outcome."
Investigations were to a standard not expected and there are serious questions over how some were down played with the review saying: "The maternity governance team inappropriately downgraded serious incidents to local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the trust went unknown until this review was undertaken."
The inquiry was ordered by Tory MP Jeremy Hunt in 2017 when he was health secretary.
He said on Wednesday the numbers were "worse" than he could have imagined and he hoped the report would be "a wake up call".
The inquiry identified "hundreds of cases" where the trust failed to undertake serious incident investigations, while deaths were not investigated appropriately.
As well as major issues within the trust, the report pointed the finger at external bodies, which did not effectively monitor the care provided.
Where investigations did take place, they did not meet expected standards and failed to identify improvements, meaning lessons could not be learned and families experienced repeated serious incidents and harm.
Donna Ockenden, the maternity expert behind the report, said: "Throughout our final report we have highlighted how 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.
"The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved.
"There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths.
"What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies.
"This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding.
"Going forward, there can be no excuses."
Ms Ockenden's team of investigators found families were locked out of reviews when things went wrong and were often treated without compassion and kindness.
The trust, which is currently ranked inadequate, was also found to have repeatedly failed to adequately monitor baby's heart rates, with catastrophic results, alongside not using drugs properly in labour.
Leaders and midwives were found to pursue a strategy of keeping Caesarean section rates low, despite the fact this repeatedly had severe consequences.
In an interim report published in December 2020, Ms Ockenden noted that for around 20 years the Caesarean section rate at the trust was consistently 8% to 12% below the England average, with this being held up locally and nationally as a good thing.
Her review team formed the clear impression there was a "culture" within the trust to keep Caesarean section rates low - perceived as the "essence" of good maternity care in the unit.
David Redford, then a clinical director of women's services in Shropshire, is on record telling several MPs in 2003 (some of whom themselves praised low Caesarean rates) that "the culture of our organisation is that we have low intervention rates and, once that is known, we attract both midwives and obstetricians who like to practise in that way."
Richard Stanton and Rhiannon Davies, who have campaigned for years over the poor care, lost their daughter Kate hours after her birth in March 2009.
The trust noted the death but described it as a "no harm" event, although an inquest jury later ruled Kate's death could have been avoided. The trust still insisted its care had been in line with national guidelines.
Another couple who have led the campaign for safer care are Kayleigh and Colin Griffiths, whose daughter Pippa died in 2016 from a Group B Strep infection. A year later, a coroner ruled her death could have been avoided.
A criminal investigation into what happened at the trust is being carried out by West Mercia Police.
In her study, Ms Ockenden identified nine areas - and 60 actions - for learning and improvement at the trust, including management of patient safety, patient and family involvement in care and investigations, complaints processes, and staffing.
In addition, 15 "immediate and essential actions" for all maternity services in England are put forward, covering 10 key areas, including that NHS England must commit to a long-term investment plan to ensure the "provision of a well-staffed workforce".
The report added that appropriate, minimum staffing levels must be agreed nationally and locally, and adhered to, while there should be a clear escalation policy when staffing levels are not met.
Furthermore, every trust should also have a patient safety specialist for maternity services, while "meaningful" incident investigations should happen, with proof of learning six months later.
Other actions include all trusts having consultants review postnatal readmissions, while bereavement services must be available seven days a week.
Some £127million has been committed by NHS England for maternity services but the report said this is "still significantly short" of the £200-£350million recommended by MPs in 2021.
Ms Ockenden said: "A death of a mother or baby, or a birth incident which results in an injury should never be ignored.
"There should never again be a review of this scale, in both numbers, and the length of years across which these concerns remained hidden."
Speaking to families and the media at the Albrighton Hall Hotel in Shrewsbury, she described leading the inquiry as "the biggest privilege of my life".
"It will remain with me forever," she said.
She added that the maternity services at the trust "failed both families across Shropshire, and sometimes their own staff, over a prolonged period of time".
She said "four key pillars" have been identified to drive forward improvements at maternity services at the trust and all other trusts across England - safe staffing levels properly funded, a well-trained workforce, learning from incidents and listening to families.
"Whilst progress has been made in some of these areas, there must now be a fully funded and then concerted effort by all NHS trusts across England to ensure that these four pillars are the foundation, the road map, and the blueprint of all maternity services going forward," she said.
"We now know that this is a trust that failed to investigate, failed to learn and failed to improve.
"This resulted in tragedies and life-changing incidents for so many of our families," she said.
Ms Ockenden said the final report spans the period from 2000 to 2019, but said she is "deeply concerned" that families continue to contact the review team in 2020 and 2021 raising concerns about the safety of maternity care they have received at the Shrewsbury and Telford Hospital NHS Trust.
"Some of these recent families contacted us with reports they wanted to share with us. We haven't been able to include them fully within the review but what we have seen is that the themes within their reports seem to echo concerns we have previously seen during this review.
"Seeing these repeated themes is a cause for grave concern.
"It is clear that there are a number of areas of maternity care where the Shrewsbury and Telford Hospital NHS Trust still ha significant learning to undertake," she said.
Louise Barnett, chief executive at the Shrewsbury and Telford Hospital NHS Trust said: "Today's report is deeply distressing, and we offer our wholehearted apologies for the pain and distress caused by our failings as a trust.
"We have a duty to ensure that the care we provide is safe, effective, high quality, and delivered always with the needs and choices of women and families at its heart.
"Thanks to the hard work and commitment of my colleagues, we have delivered all of the actions we were asked to lead on following the first Ockenden report, and we owe it to those families we failed and those we care for today and in the future to continue to make improvements, so we are delivering the best possible care for the communities that we serve."