Nearly a dozen babies and one mother died needlessly at a "seriously dysfunctional" Cumbrian hospital because of of failings "at every level", an investigation has found.
An independent report into Morecambe Bay NHS Foundation found 11 babies and a mother died unnecessarily at Furness General Hospital in Barrow between 2004 and 2013 because of a series of failures of clinical care.
Among the issues at the maternity unit raised by the report include a large proportion of staff falling "significantly below" the standard for a safe service, with essential knowledge lacking and warning signs in pregnancy not being recognised or acted on.
The report also condemned the poor working relationships between staff at the maternity unit, with midwives, obstetricians and paediatricians hampering clinical care because of a "them and us" attitude.
Dr Bill Kirkup, who chaired the Morecambe Bay investigation, said a "lethal mixture" of mistakes caused unnecessary death at the hospitals.
The report described 20 instances of significant failures of care in the FGH maternity unit that may have contributed to the deaths of three mothers and 16 babies.
In his report, Kirkup said: "Different clinical care in these cases would have been expected to prevent the outcome in one maternal death and the deaths of 11 babies.
"For the first time, the full extent of the problems have been laid bare, independently and comprehensively. Those affected by the consequences deserve to see the nature and degree of failures acknowledged, after too long hearing them denied. I am sorry that it has taken so long to happen.
"I would like to thank the families who have been harmed by these events. Without their courage in coming forward and their persistence in challenging what they were wrongly told, this investigation would not have come about."
Insistence on natural childbirth 'at any cost'
Elsewhere in the report, the investigation found how midwifery care became heavily influence by a small number of midwives who insisted on natural childbirth "at any cost" that at times led to unsafe care. It also found there was a "grossly deficient" response from unit clinicians to serious incidents which resulted in repeated failures.
The report says if these serious incidents were properly investigated, the alarm would have been raised as far back as 2004.
However, the reality of the situation only emerged in 2008 after five serious incidents emerged, but still was still only brought to wider attention in 2011.
Kirkup said: "There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health.
"Over the next three years, there were at least seven opportunities to intervene that were missed. The result was that no effective action was taken until the beginning of 2012."
Morecambe Bay NHS Foundation Trust have apologised "unreservedly" to the families. Pearse Butler, chair of the Trust board, 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.
"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."