By Becky Johnson, North Of England Correspondent
Major failure at almost every level led to avoidable deaths of babies and a mother at Furness General Hospital, a report has found.
The independent review found the maternity service was seriously dysfunctional and different clinical care would have prevented the deaths of 11 newborn babies and a mother.
Failures of knowledge, teamwork and approach to risk were all blamed and a failure to investigate problems meant the same mistakes were repeated, it said.
The report also found patients and relatives who expressed concerns were lied to and reactions of maternity staff "were shaped by denial".
The investigation, ordered by Health Secretary Jeremy Hunt, has looked into the circumstances surrounding deaths at Furness General Hospital between 2004 and 2013.
Report author Dr Bill Kirkup said: "Our findings are stark and catalogue a series of failures at almost every level."
He went on: "The nature of these problems is serious and shocking and it is important for the lessons of these events to be learnt and acted upon not only to improve the safety of maternity services but also to reduce the risk elsewhere in NHS systems."
He concluded that the hospital should formally admit the extent of the problems and apologise to patients and relatives affected for the avoidable damage caused and the length of time taken to bring mistakes to light.
He has also said there should be a review of all the skills, knowledge and competency of all obstetric, paediatric, midwifery and neonatal staff by June this year.
Better working relationships needed to be established within the hospital where midwives are described as having a "them and us" mentality, he said.
The report found that, over a nine-year period, seven opportunities were missed to rectify mistakes, including one as early as 2004.
It paid tribute to families of victims "who refused to accept what they were being told" in order to bring failures to light.
Two health watchdogs, the Care Quality Commission (CQC) and the Health Service Ombudsman, were heavily criticised for failing to respond effectively to complaints.
In total, 44 recommendations have been made to improve care both at the NHS Morecambe Bay Foundation Trust and within the wider NHS.
In a statement, the Trust said it had apologised unreservedly to those involved.
Trust chairman Pearse Butler said: "This Trust made some very serious mistakes in the way it cared for mothers and their babies.
"More than that, the same mistakes were repeated. And after making those mistakes, there was a lack of openness from the Trust in acknowledging to families what had happened. This report vindicates these families.
"For these reasons, on behalf of the Trust, I apologise unreservedly to the families concerned. I'm deeply sorry that so many people have suffered as a result of these mistakes.
"As the Chair of the Trust Board, it's my duty to ensure that lessons are learned and that we do everything we possibly can to make sure nothing like this happens again."
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