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Failures within the system have been known about, and reported on, for years. The BBC has spent more than a decade speaking to bereaved and harmed families following poor care at Morecambe Bay, Shrewsbury & Telford, East Kent, Nottingham, Leeds and a number of other NHS Trusts, gathering evidence of failing maternity services.

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"People didn't always carry the donor card on them in their pockets and handbags and the nurses and doctors didn't have time to look through. So there was a problem," Cox said.