A SORRY catalogue of mistakes, cover-up and denial made for a series of failures at "almost every level" which led to the deaths and harm of mothers and babies at Furness General Hospital.

The "shocking and saddening" failings found:

-a "lethal mix" of failures that led to the needless and avoidable deaths of one mother and 11 babies

-there were 20 instances of "significant or major failures of care"

-a "seriously dysfunctional" maternity unit with poor clinical competence, "fractured" relationships and an "over-zealous" pursuit of natural childbirth

-a "disturbing catalogue of missed opportunities" across the unit, trust and regulatory bodies

-the first sign of the presence of these problems occurred in 2004 after the death of Elleanor Bennett

Dr Bill Kirkup, a former deputy chief medical officer at the Department of Health, said different clinical care could have saved the 12 lost lives. This was four times the frequency of such occurrences at Barrow compared to the trust's maternity unit at the Royal Lancaster Infirmary.

Summarising the findings, the report outlined:

-There were clinical failures, including failures of knowledge, team-working and approach to risk. Clinical competence fell slightly below standard, guidelines were followed inconsistently and there were repeated instances to apply basic principles of care. It highlighted failures to recognise warning signs in pregnancy and uncovered extremely poor relationships between different groups of staff with a "them and us" culture.

-There were investigatory failures, by both maternity unit staff and senior trust staff, to escalate concerns that posed a threat to safety. There was an overall approach to investigations which was "rudimentary and flawed". Investigations were often carried out by the same senior midwife with reports extremely brief and showing evidence of an inappropriately protective approach to midwives, plus predominant defensive 'blame-shifting' behaviour.

-There were repeated failures to be honest and open with patients, relatives, and others raising concerns. There was a cluster of five serious incidents in 2008. What followed was a denial that there was a problem. There was a refusal to connect these incidents. A critical review report was "suppressed" internally and externally.

-There was significant organisational failure on the part of the CQC, which left it unable to respond effectively to evidence of problems. The watchdog declined a referral for an investigation into the trust in 2009 after warning bells were raised by Monitor which suspended its application for foundation trust status.

-The NW SHA and the Parliamentary Health Service Ombudsman (PHSO) failed to take opportunities that could have brought the problems to light sooner, and the Department of Health was reliant on misleading optimistic assessments from the North West Strategic Health Authority. The PHSO formed a view that there were systemic problems in the maternity unit but thought the CQC was better placed to investigate. What followed was a series of failed communications between the two bodies.