At least 20 maternity deaths or serious harm cases have been linked to a Devon hospital since 2008, according to NHS reports obtained by the BBC.
A 2017 review which was never released raised "serious questions" about maternity care at North Devon District Hospital. The BBC spent two years trying to obtain the report and won access to it at a tribunal earlier this year.
Northern Devon Healthcare NHS Trust (NDHT) said the unit was "completely different" after recommended reforms.
A 2013 review by the Royal College of Obstetricians and Gynaecologists (RCOG) investigated 11 serious clinical incidents at the unit, dating back as far as 2008.
The report identified failings in the working relationships at the unit, finding some midwives were working autonomously and some senior doctors failed to give guidance to junior colleagues.
Despite the identified problems with "morale", the subsequent investigation by RCOG in 2017 expressed concerns with the "decision-making and clinical competency" of senior doctors and their co-operation with midwives.
An independent review into midwifery in October 2017 noted "poor communication" between medical staff on the ward for more than a decade. The report identified a "lack of trust and respect" between staff and "anxiety" among senior midwives at the quality of care.
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Source: BBC News, 16 March 2020