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British Health Secretary Sajid Javid says changes will be made at a local and national level following a damning report into maternity services provided by the Shrewsbury and Telford National Health Service (NHS) Trust which, over a period of two decades, may have led to the deaths of more than 200 babies.
The report highlighted a lack of accountability and investigation into mistakes and errors of practice, major concerns over the standard of care, understaffing and a lack of continuous training, and a culture of not listening to families affected by incidents.
When the inquiry was set up in 2017, it was to look at 23 cases, but it ended up taking in more than 1600, in one of the biggest probes of its kind in the history of the NHS. The trust has apologized and pledged to make significant changes to how it operates.
Javid called the report's findings "stark and deeply upsetting", and said several people implicated by it had been suspended or struck off. The case is also the subject of a police inquiry.
"To all the families who have suffered so greatly, I am sorry," said Javid.
"The report clearly shows that you were failed by a service that was there to help you and your loved ones to bring life into this world; we will make the changes that the report says are needed at both a local and national level."
One of the affected mothers, Julie Rowlings, whose daughter Olivia died after a prolonged labor, said: "I feel like after 20 years, my daughter finally has a voice.
"For every family out there, every family that's come forward, this is for them. Justice is coming. For every baby, justice is coming."
Senior midwife Donna Ockenden, who was in charge of the inquiry, set 84 recommendations for improvement, including 15 that were described as "immediate" actions to be taken by all maternity services in England. She also said she was "deeply concerned" that families were still getting in touch in 2020 and 2021 with concerns about the standard of care they received at the trust.
"Seeing these repeated themes is a cause for grave concern," she said. "It is clear that there are a number of areas of maternity care where the Shrewsbury Telford Hospital NHS Trust still has significant learning to undertake," she said.
No arrests have yet been made or charges brought by West Mercia police, who are conducting the police inquiry, but Detective Chief Superintendent Damian Barratt told the Guardian newspaper that its investigation, known as Operation Lincoln, was "very much active".
"We will be fully reviewing the findings of the report and feeding appropriate elements into our investigation," he added.
"We do not underestimate the impact the report's findings and our ongoing investigation has on the families involved, who have suffered unimaginable trauma and grief that they still live with today."