Hundreds of babies died or were left disabled due to poor care during birth according to a probe in to the biggest maternity scandal in NHS history.
Today a report identified at least 201 babies and nine mothers who may have survived had they had proper care at Shrewsbury and Telford Hospital NHS Trust.
At least 94 more babies suffered avoidable brain injuries.
There were at least 304 cases of serious harm, the report by Donna Ockenden found.
Botched births meant mothers and babies died and some newborns were left brain damaged - all while SaTH was being held up as an example of good practice due to its low caesarean rates.
Mothers were denied C-sections and forced to suffer traumatic births as many babies were left with fractured skulls and broken bones while others were starved of oxygen and suffered life changing brain injuries.
Ms Ockenden, who led the inquiry, told a press conference that maternity services had "failed both families across Shropshire, and sometimes their own staff, over a prolonged period of time".
The report stated: “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.
“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.”
The Ockenden review was launched in 2017 by then Health Secretary Jeremy Hunt on the basis of 23 deaths at the trust.
Since then 1,486 families came forward to add their case to the inquiry with the earliest case from 1973 and the latest from 2020.
Of these 1,592 were taken forward as part of the review.
Bereaved parents have called for prosecutions, and it is understood that West Mercia Police are carrying out a parallel investigation.
Richard Stanton, whose daughter Kate Stanton-Davies died during birth in 2009, said before the report was published: “This is a watershed moment for maternity care across the NHS.
“SaTH was a horrendous case but they were not an isolated trust. You only have to look in East Kent and Nottingham where hundreds more families are coming forward to express concern about the care they received.
“I hope the police will now have sufficient evidence to present to the CPS for a prosecution.
“SaTH should suspend senior managers who have been promoted or moved sideways. They have overseen the culture of normal births at all costs.”
Richard’s wife Rhiannon Davies gave birth in a midwife-led unit run by the Shrewsbury trust in March 2009 where there were no doctors. She remembers “the midwives encouraged us to go there to ‘keep their numbers up’”.
Rhiannon’s pregnancy was wrongly classed as low-risk and she should have given birth at a hospital where doctors were on hand.
The couple embarked on a mission to discover how their daughter had died and found many others had gone through a similar experience.
A dossier compiled by Rhiannon and another bereaved mother Kayleigh Griffiths led to the Government commissioning the Ockenden review.
A five-year investigation by a team of 90 expert midwives and doctors examined the experiences of 1,500 families after a total of 1,800 complaints about births at the trust between 2000 and 2019.
At least 12 mothers died while giving birth, and some families lost more than one child, the report is expected to show.
The report will have implications for NHS England, the Nursing and Midwifery Council (NMC), the Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) - all of which pushed targets for natural births that have since been scrapped.
