A senior midwife at the heart of a baby death scandal has admitted repeatedly failing to properly investigate her colleagues' shortcomings.
Jeanette Parkinson, the former maternity risk manager at University Hospitals of Morecambe Bay Foundation Trust, committed misconduct due to her "inadequate" review into the deaths of two mothers and three babies.
A hearing at the Nursing & Midwifery Council (NMC) was told Ms Parkinson did not inform the health authorities of her fellow midwives' shortcomings in caring for patients who later died.
The oversights between 2008 and 2009 included failure to monitor a unborn baby's heart rate and an inadequate 32-week review of an expectant mother.
Because Ms Parkinson did not report the episodes, neither the quality of care or standard of midwifery were investigated in several cases.
An inquiry into the trust in 2015 found a "lethal mix'' of failures at the health organisation led to the unnecessary deaths of 11 babies and one mother between 2004 and 2013.
On Monday, Ms Parkinson admitted a string of charges - which concluded her "inadequate analysis" into the care led to risk not being properly considered - and that she was was no longer fit to practice.
She denied failing to report keeping records in two cases of caring for mothers and their babies and not reporting a midwife not following clinical procedures.
Grace Hansen, representing the NMC, said on Monday: "Jeanette Parkinson was employed as a maternity risk manager at University Hospitals of Morecambe Bay Foundation Trust between 2004 and 2012.
"Ms Parkinson was also appointed as supervisor of midwives by the professional local supervising authority and that from November in 2008 there were two maternal and three neonatal deaths at Furness General Hospital, one of the hospitals at the trust.
"The charges brought by the NMC ... relate to Ms Parkinson's inadequate investigation of each of these tragic events on behalf of the trust or the LSA.
"Ms Parkinson has admitted many of these charges and accepts that they amount to misconduct and that her fitness to practice is impaired by reason of that misconduct.
"The parties agree that the only appropriate and proportionate sanction is a striking-off order."
The panel then retired to consider whether Ms Parkinson should be struck off from the medical register.
The midwife was suspected to be a member of a close-knit group of staff known as the "musketeers" - so named because of their "one-for-all" approach in dealing with criticism.
A culture of defensiveness, denial and blame-shifting was said in the 2015 review to have evolved when it became obvious there were serious problems within the unit.
Among a catalogue of allegations made against Ms Parkinson by the 2015 panel was that she had helped write and circulate answers for the midwives' evidence at the 2011 inquest into the death of newborn Joshua Titcombe.
The review also flagged concerns her role as midwife supervisor and risk manager posed a conflict of interest which compromised her objectivity.
On Monday, the NMC acknowledged the years it had taken to bring action against the midwife would have impacted the bereaved families.
"The NMC recognises the length of time which has passed since 2008 and acknowledges the delay and the impact this has caused the families who have been contacted for comment," Ms Hansen said.
Three of the families affected were said to have been contacted by the NMC - but the fourth were not out of concern it might "distress" them to discuss the case, the hearing was told.
Ms Parkinson is the seventh midwife to be probed by the NMC over the scandal, two of whom were also struck off while another was suspended.
In a review into the death of one mother, known as Patient D, Ms Parkinson failed to report that at a 32-week review she had not had her blood pressure taken, urine tested and there was not an appropriate risk assessment of her need for specialist review.
She incorrectly concluded: "These factors do not appear to be directly related to (Patient D's) death."
Ms Parkinson was found to be "significantly overpaid" by as much as 14 months under a redundancy agreement with the trust in 2012, sparking a "fit and proper" investigation into HR manager Roger Wilson.
The Morecambe Bay investigation found staff had the opportunity to "make a clean break" from a previous pattern of defensiveness in the face of criticism.
Instead, the position of the midwives became "more firmly entrenched" and led to some "grossly inappropriate actions that we believe constituted inexcusable derelictions of professional duty".