I have worked with many families who have lost babies and mothers during or shortly after birth. While working at law firms, it was my role to protect them from unwanted media intrusion or, conversely, to help them speak out in the media to find the answers to why their loved ones died.

We all say we can’t know what it’s like to be in their position if we haven’t been through it, but we can all imagine a fraction of our worst fears; deep down, where we don’t want to go, we can conjure in our minds the utter despair of losing a child or partner.  

It is bad enough to think that this happens in some tragic unavoidable circumstance; the pain of losing someone softened only slightly, knowing that professionals had done everything to save them. Then imagine the grief when you find out that the death was avoidable.

On Wednesday 30th March, the largest ever inquiry into NHS maternal care will publish their findings into Shrewsbury and Telford NHS Trust. The Ockenden Maternity review is expected to reveal the full extent of failings at the Trust. A criminal inquiry into deaths at the Trust is also currently underway.

The inquiry, led by expert midwife Donna Ockenden assisted by 90 midwives and doctors, is expected to deliver a damning verdict on the Shrewsbury trust, culture, and leadership.

Whilst working on similar medical negligence cases from another Trust, I remember asking a lawyer: “How can this happen?” she turned and said simply: “bad eggs’. 

An interview with a former consultant obstetrician at the Shrewsbury and Telford NHS Trust bears this out as he described "a climate of fear" among staff who tried to report concerns. Bernie Bentnick who worked at the Trust for 30 years described how deaths kept occurring due at least in part to “resources and the institutionalised bullying and blame culture.”

According to Shaun Lintern in the Sunday Times, one of the key findings in the Ockenden Maternity Review will be that 300 babies died or were left brain damaged due to avoidable errors.

Shaun is probably closer to this issue than any other journalist working today. During his time at a regional newspaper, he shone a light on the care at Mid-Staffordshire hospital. Sitting through all 139 days of the inquiry into that hospital in 2011, writing 130,000 words on the scandal, he describes how the story changed his life.

The Francis report published in 2013 by Sir Robert Francis found “an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities” at mid-Staffordshire hospital.

Sir Robert Francis said staff at the hospital were aware of issues but were afraid of speaking out about them amidst a climate of fear and a culture of bullying which permeated the hospital. Despite the resulting recommendations from the Francis Report and promises from those in power that it must not happen again, it has. 

As Mr Bentick says: “In Shrewsbury and Telford, there was a climate of fear where staff felt unable to speak up because of risk of victimisation".

The ‘bad eggs’ remain to create a climate of fear and a culture of bullying. How can this be that in a space entirely geared to the care of people, there are repeatedly avoidable deaths caused, at least in part, by culture and behaviour that is not tolerated in any other workplace?

I love the NHS. Our health system is the envy of the world and the envy of those who would seek to make a profit from it by moving it into the private sector. These poor decisions would multiply if profit were ever a motive, so I hope this doesn’t read as an attack on the NHS.

It would not be suitable for me to sit here with only user experience, to start saying how it should function. But my experience with bereaved relatives has changed me over the years, coupled with my own experience of the traumatic birth of my first son.

However, until the NHS, and its guardians at the Ministry of Health, start to accept these bad eggs exist, we will keep having these inquiries. We must find genuinely motivated and caring recruits of all ages to match those working within the NHS to the highest standards and eradicate toxic behaviours. 

We must also demand that the NHS is adequately funded; its failure must not be induced by outside interests looking to deliver a new solution that puts profit into our health service.

Follow at @DaveStandard

Dedicated to all those parents who have been braver than I think I ever could. If you have been affected by any of these issues please seek others who have been in your position visit www.babylifeline.org.uk, www.childbereavementuk.org and many other organisations who are there for you online and in person.

If you want to campaign or start a petition about this issue or any other please see www.findothers.com see how you can start.