Commenting on the findings of the East Kent NHS inquiry into the avoidable deaths of at least 45 babies, Ombudsman Rob Behrens said:
"The Kirkup investigation makes distressing reading. It has only been a few months since the Ockenden report found devastating failures in maternity services. The phrase ‘never again’ is starting to ring hollow. At what should be the happiest of times, mothers should not have to be anxious about the care they will receive.
"For the second time this year, we are hearing about major failures within maternity services spanning many years. We are currently reviewing our recent maternity care cases to identify common themes and shine further light on areas that need improvement.
"It’s vital that lessons are learned and action taken to avoid the trauma, pain and suffering that impacts on families when maternity services fail and policy makers say ‘this must not happen again’."