A major report into maternity failings at an NHS trust has found at least 210 deaths could have been avoided.
At least 201 babies could have lived if their care had been better, including 131 who were stillborn and 70 who were born soon after birth.
Nine mothers also died avoidable deaths.
In 94 cases babies suffered avoidable long-term injuries, including brain damage, due to a lack of oxygen during their birth.
The major report into more than two decades of avoidable harm to babies and mothers at the Shrewsbury and Telford NHS Trust has found mothers were blamed for deaths of their babies. Some families were told mothers were responsible for their own deaths.
The independent review chaired by midwife Donna Ockenden examined 1,592 clinical incidents involving 1,486 families. Most of the incidents occurred between 2000 and 2019.
It found a culture that favoured natural birth led to a reluctance to perform caesarean sections which resulted in many babies dying.
Major report into maternity scandal at NHS trust where hundreds of babies died or left brain damaged to be revealed
Shrewsbury maternity scandal: The babies who died in the UK’s worst hospital childbirth scandal
MP Jamie Wallis says he is trans as he reveals rape ordeal and £50,000 blackmail plot against him
There was a failure to properly assess the risk of patients, a failure to properly monitor babies and a repeated failure to learn from mistakes.
Chair of the review Donna Ockenden 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 fetal 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, Trust boards must be held accountable for the maternity care they provide. To do this, they must understand the complexities of maternity care and they must receive the funding they require.”
Her report issues more than 60 areas in which the Shrewsbury and Telford Trust must take action.
The review has also outlined 15 areas in which all maternity services in England must take action to improve patient safety.
