An NHS trust has today been condemned for poor practice by the health watchdog, following the deaths of ten women who gave birth in one of its hospitals.
The Healthcare Commission said the "sad and tragic series of events" at Northwick Park Hospital between April 2002 and April 2005 were caused by a lack of sufficiently skilled staff, a failure to properly assess patients and a lack of professional support.
Consultant obstetricians did not conduct any kind of routine observations of their patients, it finds - one woman who died had only been seen once in the seven days she was in the hospital before giving birth.
There was also an over-reliance on junior staff - in one case, it took three calls to the consultant obstetrician to get them to attend, something today's report says is "unacceptable".
In this same case, the watchdog also finds "serious inadequacies" in the care provided by the midwives after birth. Across all but one of the cases, it finds there were not enough midwives employed, and those that were suffered from a lack of professional support.
The Healthcare Commission found no faults in one case, and praised the anaesthetic and haemotology staff across the board for their work. It also recognised that the hospital was "fraught with tensions" at the time of the deaths, and said staff did try their best.
Today's report is the second from the Healthcare Commission into the events at Northwick Park hospital - the first, last year, resulted in the hospital being placed under special measures.
Since 2005, North West London Hospitals NHS trust has employed an extra three consultant obstetricians, 20 midwives and a number of extra nurses at the hospital's maternity unit, while the labour ward has also been refurbished.
But the watchdog felt a second report was required into the specific care received by the ten women who died, after it concluded that the trust had not taken enough action.
"This was a sad and tragic series of events. We hope this report at least gives some answers to the families involved," said Marcia Fry of the Healthcare Commission.
"At the time of the deaths, the working practices at the trust were unacceptable. However, under special measures the trust has got its maternity services on the road to recovery."
She added: "Most women in this country give birth safely. But there are risks and the NHS must ensure it does all it can to reduce them. There can be no excuse for failing to learn the lessons from tragedies of this kind."
The Royal College of Midwives (RCM) welcomed today's report but said it believed lessons had been learned at the hospital concerned, and the extra staff would make a difference.
Southern regional manager Melanie Every added: "The RCM has made repeated calls to government to ensure that the numbers of midwives in service are sufficient to provide safe care and we are carefully monitoring other changes to midwifery care given the financial crisis in the NHS at present."