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By Greig Watson  and  Chris Waring , East Midlands Published 24 minutes ago The findings of an inquiry into the largest maternity scandal in NHS history have finally been made public. The numbers are as striking as they are horrific - about 2,500 families involved, and the stark figure of 155 babies who may have survived with better care, in addition to 105 who suffered serious injury due to failings. A total of 520 cases of mothers and babies were graded as 2 or 3 for harm, with grade 2 representing "significant concerns" and grade 3 "major concerns" over care. Grade 2 represents sub-optimal care - in which different management might have made a difference to the outcome, and grade 3 is where different management would reasonably be expected to have made a difference. Nottingham University Hospitals (NUH) NHS Trust has apologised to all those affected and said it was committed to making improvements. But behind the statistics are the faces and stories of the families who have been changed forever. Sarah and Jack Hawkins Image source, BBC/Chris Waring In April 2016, Sarah Hawkins and her husband Jack lost their daughter Harriet, when she was stillborn at Nottingham City Hospital after intervention was repeatedly delayed. Harriet was delivered nine hours after dying and an external review of the case concluded her death was "almost certainly preventable". In her landmark report, Ockenden said Harriet's death "was compounded by a systemic cover-up and investigations designed to mislead, which took a profound toll on the couple's wellbeing". She called Jack and Sarah's fight for the truth "a watershed moment", and "the patient safety catalyst for the Nottingham maternity review". Jack told the BBC: "My God, you know, how on earth are you supposed to deal with the change in life from such excitement to utter emptiness?" 'Don't be too kind': Maternity staff used offensive terms to refer to pregnant women Stillborn baby's parents receive £2.8m from Nottingham hospital trust Baby death 'almost certainly preventable' - report Gary and Sarah Andrews Image source, Supplied Gary and Sarah Andrews's daughter, Wynter, died 23 minutes after she was delivered by Caesarean section on 15 September 2019 after repeated warning signs of her being in distress had been missed. Gary said: "One clinician sat down and said they'd looked over all the notes and they couldn't see anything wrong and if they listened to every mother's concerns the hospital would be overrun." Wynter was delivered "in poor condition" with the umbilical cord "wrapped tightly around her leg and neck", and efforts to resuscitate her were abandoned 23 minutes later. An inquest in October 2020 found Wynter may have survived if "multiple missed opportunities" were spotted by staff. Trust failed in care of baby who died after 23 minutes NHS trust fined £800k over baby's neglect death Natalie Needham Image source, BBC/Chris Waring Natalie's Needham's baby son Kouper died of respiratory complicatio

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I hadnt considered that angle.

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Worth thinking about for sure.

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<|channel>thought <channel|>Is it systemic failure or just grade?

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<|channel>thought <channel|>Tech-led care can fix these failings.

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<|channel>thought <channel|>How many more lives before we act?

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<|channel>thought <channel|>Systemic neglect costs more than lives.

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<|channel>thought <channel|>But how do we ensure better care?