A review into baby deaths at a scandal-hit NHS trust said maternity staff had caused distress to patients by using "inappropriate language" and blaming grieving mothers for their loss.
The inquiry into deaths and allegations of poor care at Shrewsbury and Telford Hospital NHS Trust (SaTH), set up in 2017, identified seven "immediate and essential actions" needed to improve maternity services in England.
The report said that when completed, the review of 1,862 families "will be the largest number of clinical reviews undertaken relating to a single service, as part of an inquiry, in the history of the NHS".
Former senior midwife Donna Ockenden's report said "one of the most disappointing and deeply worrying themes" was the "reported lack of kindness and compassion from some members of the maternity team at the trust".
The chief executive of the trust apologised for the "pain and distress" caused to mothers and families due to poor maternity care – after the review found staff had been "flippant", "abrupt" and "dismissive".
The review also said the deaths of Kate Stanton Davies in 2009 and Pippa Griffiths in 2016, whose families had campaigned for an independent review into maternity care at the trust, "were avoidable".
Responding to the report, patient safety and maternity minister Nadine Dorries said she expects the SaTH to act on the recommendations immediately following the "shocking" failings.
The "emerging findings" report was published on Thursday, based on a review of a selection of 250 cases of concern, which include the original 23 cases which initiated the inquiry.
Ms Ockenden, chair of the independent maternity review, described the initial recommendations – including a call for risk assessments throughout pregnancy – as "must dos" which should be implemented immediately.
Speaking of the lack of compassion and kindness shown by staff, the report said: "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."
In the review, seven "immediate and essential actions" were recommended for across England, which included risk assessments throughout pregnancy and monitoring foetal wellbeing.
The other recommendations included enhanced safety, listening to women and families, managing complex pregnancy, and staff training and working together.
Addressing the scope of the review in the report, it said: "Direct contact from families together with the trust's referrals led to us reporting in July 2020 that the review numbers had increased to encompass 1,862 families.
"It is likely that, when completed, this review of 1,862 families will be the largest number of clinical reviews undertaken relating to a single service, as part of an inquiry, in the history of the NHS."
Speaking after the report was published, Ms Ockenden said in a statement that mothers had been "denied the opportunity to voice their concerns about the care they have received... for a long, long time".
She said the care at the trust had "caused untold pain and distress, including, sadly, deaths of mothers and babies".
Ms Ockenden added: "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."
The first report outlines local actions for learning and immediate and essential actions to improve safety in maternity services for the SaTH and across England#ockendenmaternityreviewhttps://t.co/AXpJKp947P
— Donna Ockenden (@DOckendenLtd) December 10, 2020
West Mercia Police have also launched their own investigation to establish if there are any grounds for criminal proceedings.
The 27 local actions for learning involve recommendations around general maternity care, maternal deaths, obstetric anaesthesia and neonatal care.
The report into maternity care at the Shropshire trust said the review of 250 cases had "identified missed opportunities to learn in order to prevent serious harm to mothers and babies".
It added: "However, we are unable to comment any further on any individual family cases until the full review of all cases is completed."
The review team had also found "inconsistent multi-professional engagement" with the investigations into serious incidents in the trust's maternity services.
The report stated: "There is evidence that when cases were reviewed the process was sometimes cursory. In some serious incident reports the findings and conclusions failed to identify the underlying failings in maternity care.
"The review team has also seen correspondence and documentation which often focused on blaming the mothers rather than considering objectively the systems, structures and processes underpinning maternity services at the trust."
In a statement issued after the report was published, Kim Thomas, chief executive of the Birth Trauma Association, said: "Once again we have a damning report of failings in care at a maternity unit.
"Mothers and babies have died as a result of poor team working, a failure to learn from mistakes, a culture of cover-up and an obsession with keeping caesarean rates low.
"It is time that maternity units throughout the country are properly monitored so that we can see just how widespread these failings are and to put in place measures that will ensure every woman receives good quality, evidence-based maternity care."
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."