Eleven babies and one mother died following "a lethal mix" of failures in a "seriously dysfunctional" maternity unit at Furness General Hospital, an independent inquiry has found.
The Chairman of the Morecambe Bay Investigation, Dr Bill Kirkup, has said there was a "disturbing catalogue of missed opportunities" at Morecambe Bay NHS Foundation Trust.
He said had proper investigations into serious incidents been conducted as far back as 2004 it would have raised the alarm about the level of maternity and paediatric care being provided.
"There was a disturbing catalogue of missed opportunities, initially and most significantly by the Trust but subsequently involving the North West Strategic Health Authority, the Care Quality Commission, Monitor, the Parliamentary and Health Service Ombudsman and the Department of Health," Dr Kirkup said.
"Over the next three years, there were at least seven opportunities to intervene that were missed. The result was that no effective action was taken until the beginning of 2012."
A man whose wife and son died at Furness General Hospital says he has never received an apology for failings which led to their deaths.
A "lethal mix" of poor clinical care and relationships between doctors and midwives led to the deaths of 11 babies and one mother.
A damning report out tomorrow is expected to reveal the deaths could have been prevented if staff had not been 'at loggerheads'.