Hospitals across England are being urged to make changes to their maternity care following the deaths of hundreds of infants at an NHS trust.
A review launched at the Shrewsbury and Telford Hospital NHS Trust to investigate a number of baby deaths has found "seven immediate and essential actions" to improve care.
The recommendations in the report includes conducting risk assessments throughout pregnancy and monitoring foetal wellbeing, enhanced safety checks, listening to women and families, managing complex pregnancies, and more staff training.
An inquiry into the deaths, and numerous allegations of poor care was set up in 2017 and is now examining the cases of 1,862 families, with the majority of incidents occurring between 2000 and 2019.
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The report also found maternity staff had caused unnecessary distress to patients include "inappropriate language", as well as blaming those who are grieving for their children for their loss.
There was also a reluctance to conduct caesarean sections, a tendency to blame mothers for problems, a failure to handle complex cases, a lack of consultant oversight, and a 'deeply worrying lack of kindness and compassion'.
The lack of care greatly contributed to the deaths of hundreds of babies, the report said after it was published on Thursday. It was comprised a review of a selection of 250 cases of concern, which include the original 23 cases which saw the initial launch of the inquiry.
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Concerns had been raised by the parents of Kate Stanton-Davies and Pippa Griffiths, who sadly died after birth in 2009 and 2016.
Speaking about its findings, the report reads: "Many of the cases reviewed have tragic outcomes where kindness and compassion is even more essential. The fact that this has (been) found to be lacking on many occasions is unacceptable and deeply concerning.
"Evidence for this theme was found in the women's medical records, in documentation provided by the trust and families, in letters sent to families by the trust and from through the families' voices heard through the interviews with the review team.
"Inappropriate language had been used at times causing distress. There have been cases where women were blamed for their loss and this further compounded their grief.
"There have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all."
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West Mercia Police have now launched their own investigations to see if there are any grounds for criminal proceedings.
Former senior midwife Donna Ockenden, chair of the independent maternity review, called for the changes to be put in place with immediate effect.
After the report was published, Ms Ockenden said mothers had been "denied the opportunity to voice their concerns about the care they have received."
"The trust had caused untold pain and distress, including, sadly, deaths of mothers and babies.
"Many families have suffered long-term mental health problems. They say their suffering has been made worse by the handling of their cases by the trust."
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Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust, said: "I would like to thank Donna Ockenden for this report but more importantly the families for coming forward. As the chief executive now and on behalf of the whole trust, I want to say how very sorry we are for the pain and distress that has been caused to mothers and their families due to poor maternity care at our trust.
"We commit to implementing all of the actions in this report and I can assure the women and families who use our service that if they raise any concerns about their care, they will be listened to and action will be taken."
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