A 'LETHAL' mix of failures at "almost every level" including a dysfunctional maternity unit and a subsequent cover-up led to the unnecessary deaths of 11 babies and one mother at a South Cumbria hospital.

The damning report into deaths of mothers and babies at Furness General Hospital (FGH) between January 1, 2004, and June 30, 2013 uncovered 20 instances of "significant failures of care" under the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT).

Dr Bill Kirkup, who chaired the inquiry which was ordered by health secretary Jeremy Hunt in 2013, revealed a catalogue of mistakes may also have contributed to the deaths of a further two mothers and five other babies.

The investigation found there were nine significant missed opportunities - seven in 2008 alone - to intervene, amounting to a cover-up which saw senior staff, management and regulatory bodies reject the concerns of families, collaborate to conceal the truth and fail to respond to clear warning signs.

This, Dr Kirkup said, was "inexcusable", "dishonest" and "unforgivable".

The report revealed the origins of the problems in the department was a result of a tight-knit group mentality among midwives who dubbed themselves the "musketeers", making for a "them and us" culture between staff groups.

And while the bereaved parents and partners said they felt "vindicated" in light of the "disturbing catalogue" of failings finally being brought to the surface, they said their fight would not be over until the recommendations were fully implemented and those involved were held to account.

For some, in the case of Lesley Bennett who lost her daughter Elleanor in 2004, the resolution being sought is prosecution.

This newspaper now echoes the families' calls for people to be held to account over the preventable deaths of their loved ones.

Laying bare for the first time the full extent of the problems surrounding the scandal-hit hospital, the independent investigation found a number of "shocking" failures at "every level" - from the maternity unit itself through to health regulators.

Slamming the dysfunctional maternity unit, the report outlined a series of problems including clinical competence being substandard with a deficiency of skills and knowledge, "extremely poor" and "fractured" relationships, and a growing move among midwives to "pursue a normal childbirth 'at any cost'".

The report also described how the senior midwife and maternity risk manager "prepared a single set of what we can only regard as 'model answers'" to a set of difficult questions which she circulated ahead of the inquest into James Titcombe's son Joshua who died in November 2008.

This was part of a systematic distortion of the truth in the ward which had an already "rudimentary and flawed" overall approach to investigations.

After the publication of the report, UHMBT medical director David Walker said seven midwives had been subjected to trust disciplinary processes and of those two were dismissed, three had written warnings and two had verbal warnings.

He said midwives were referred to the Nursing and Midwifery Council and three of them were yet to hear from the authority about what action going to be taken.

Competency hearings are planned and scheduled for four midwives.

Mr Walker also said five doctors had been subjected to trust disciplinary procedures and of those, two were given verbal warnings, one had retired, and one had resigned.

The latter, he said, would be brought before the General Medical Council for a fitness to practice hearing in the future.

But it was the delay, denial and overall cover-up within the trust itself and the failure to investigate warning signals that displayed a "significant organisational failure" among the board and regulatory bodies.

It was not until 2008, the report said, that concerns over the maternity ward surfaced to trust board level but the then chief executive Tony Halsall failed to connect a cluster of five serious untoward incidents that year.

By 2009 a nurse responsible for clinical quality said she was concerned about a "gap in investigations" of that very cluster.

Despite the proposal of an external review from the trust, which later became the Fielding report, Dr Kirkup found that the chief executive and nurse director Jackie Holt had "shifted" the emphasis from what had happened to what should be done to move forward.

Dr Kirkup concluded there was an element of "conscious suppression" of the Fielding report in order to gain a clean bill of health from NHS regulators.

This laid the foundations for a further catalogue of failures to address concerns within the ward due to a lack of effective communication between regulatory bodies including the North West Strategic Health Authority, Care Quality Commission, Monitor, the Parliamentary Health Service Ombudsman and the Department of Health.

Responding to the report, UHMBT chief executive Jackie Daniel described it as a "definitive picture of what happened between 2004 and 2013" and said she "apologised unreservedly".

"It's very clear from the report that there were very serious failures in clinical care," she said. "We accept and acknowledge all of those criticisms.

"During the period of this investigations there were some very serious failings, and the trust then failed to show openness and transparency in acknowledging those failings. I want to say sorry to all of those who have suffered."

The trust assured changes had already been made.

These included the hiring of more midwives and doctors, an entirely new trust board, and an improvement in culture, team-working and patient safety.

But Ms Daniel did confirm some staff mentioned in the report remained at the hospital.

The report did however reveal staff were still "unable to recognise there could have been failures of care in 2008".

Ms Daniel said one of the recommendations in the report would mean establishing that staff understand those problems. If they didn't, further action would be taken, she said.

The trust said it was liaising with Cumbria Police following the publication of the report.