The Royal College of Physicians (RCP) investigation, which followed the Ockenden report that looked at almost 1,500 cases over a number of decades, examined 18 deaths at the trust between 2021 and 2022.

While the review did not identify evidence to indicate the quality of care was substandard or contributed to the trust's higher than normal perinatal fatality, it did find examples of poor care and in one instance very poor care.

The review noted ‘neonatal mortality at SaTH cannot be considered in isolation to neonatal mortality across the region', highlighting the West Midlands has the highest infant mortality in England with 5.6 deaths per 1,000 live births.

The RCP suggested the need to investigate wider social determinants behind the data, including poverty and ethnicity.

Dr John Jones, executive medical director for SaTH, said: ‘Our neonatal teams care for unwell babies through the early critical days of their lives. We owe it to them and their families to give the best care. We wanted to understand how our services could be improved, and anything we could do to reduce the above-average perinatal mortality rates in the trust and across the West Midlands.

‘We have written to each of the 18 families whose baby or babies' care was reviewed and have begun meeting with them, in person, to answer any questions and to offer support. We are grateful for their time and willingness to engage with us as we seek to improve our services wherever possible.'