Three women who died under the care of a hospital's maternity unit may have survived if earlier recommendations had been implemented, a report has said.
The cases occurred at University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust over 16 months.
A review by the Healthcare Safety Investigation Branch (HSIB) also found a culture of intimidation and bullying.
The report found that although there was no common theme to the deaths - and four other life-threatening cases that occurred in the same period - processes and leadership had been inconsistent and fragmented.
HSIB said "robust action planning and prompt addressing of the learning" from previous recommendations from other investigations "may have had an impact on the outcome for the women who received care during the seven events included in this thematic review".
Source: BBC News, 22 February 2023
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