Key findings:
A culture where mistakes were not investigated and a failure of external scrutiny
Parents were not listened to when they raised concerns about the care they receive
Where cases were examined, responses were described as lacking "transparency and honesty"
The trust failed to learn from its mistakes, leading to repeated and almost identical failures
A culture of bullying, anxiety and fear of speaking out among staff at the trust "that persisted to the current time"
Caesarean sections were discouraged, often leading to poor outcomes
“ 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." Donna Ockenden