A British hospital group scandal-hit by scandals was subject to a review that found Wednesday that more than 200 babies died from preventable causes over the past two decades.

After two families lost their babies to the Shrewsbury and Telford NHS trusts in west England, a review was initiated in 2018.

Donna Ockenden, a former senior midwife, led an investigation into nearly 1,600 incidents that occurred between 2000 and 2019. This included cases of stillbirth, neonatal deaths, and other serious complications for mothers and babies.

The investigation revealed that 131 stillbirths, 70 deaths in neonatal care and nine maternal deaths could have or should have been prevented with better care.

Ockenden stated Wednesday that the hospital management had “failed to examine, failed to learn, and failed to improve.”

She said, “This led to tragedies and life-changing events for so many families.”

Sajid Javid, Health Secretary, said Ockenden’s report showed “a tragic picture of repeated failures and care.” He also mentioned a case in which “important clinical information” was stored on Post-it notes that were then thrown into the trash by cleaners. This had tragic consequences for a newborn baby as well as her family.

Javid stated, “To all families that have suffered so severely, I am sorry.”

He assured the families of those who have lost loved ones that they would hold people accountable. He said some staff had been fired or banned from practicing and that 600 incidents were being investigated by police.

Ockenden’s 2020 initial report found that there was a pattern of maternal neglect and failures that led to unnecessary deaths and harm for mothers and their newborns. It stated that deaths were not always investigated and that grieving mothers were sometimes blamed for their loss.

Ockenden stated that the hospital was focused on keeping the rates of cesarean sections low and that some C-sections could have been performed earlier to avoid injury and death.

Ockenden stated Wednesday that she was “deeply worried” by the fact that families continue to contact the review group in 2020 and 2021, expressing concerns about the safety of the hospital’s care.

Ockenden stated that there has been some progress since her 2020 Report, but that “systemic” improvements were needed throughout the country. This included funding and staffing of maternity units.

Louise Barnett, chief executive of Telford NHS Trust in Shrewsbury and Telford, offered her “wholehearted apologies.”

She stated that “we owe it all to the families that failed, and to the people we care for today and tomorrow to continue making improvements.”

Julie Rowlings, the mother of Olivia, was happy with the strong conclusions.

She said, “I feel like my daughter finally has voice after twenty years.”

This is for every family, every family that has come forward. Justice is coming. Justice is coming for every baby.