This final report is being made available today at the today at the request of the family and with their explicit consent.
The Hospital reiterates its apologies to Mr and Mrs X. The Hospital has fully accepted the findings.
An action plan for the implementation of the recommendations specifically for the Hospital was developed and all recommendations are now implemented locally.
The Hospital is committed to learning and improving the experience of women and families who use our services every day.
This report and its recommendations have been shared with the National Women and Infants Health Programme to ensure learning across all maternity services.