FAILINGS in the standard of care provided at Wyre Forest Birth Centre may have contributed to the death of babies, a damning report has found.

An independent inquiry, set up after six babies died unexpectedly at the midwife-led centre in less than three years, found only one had a significant congenital problem - a heart defect.

John Rostill, chief executive of Worcestershire Acute Hospitals NHS Trust, welcomed the findings and said he would not consider reopening the centre for "low-risk births" unless he was "completely satisfied" a raft of 27 recommendations had been implemented.

He described the report as "a catalogue of issues that need to be corrected".

The report says the investigation revealed "failings in the standard of care provided, some of which were serious and may have contributed to the outcomes".

The inquiry team also uncovered evidence that highlighted "more systematic weaknesses in the way mothers and babies were cared for at the birth centre".

"The failings covered all stages from the booking of mothers for delivery at the birth centre to the support given to bereaved parents," adds the report.

It says the centre, which delivered an average of 228 babies a year, was adequately staffed and staff were experienced, caring and committed. But there were gaps and shortcomings in training and very little evidence of a learning culture.

Relationships with the rest of the trust were poor and resistance to change was marked in some staff.

Mr Rostill said he did not anticipate anyone being asked to leave for the time being.

"The report describes a far from satisfactory situation and I have to say I'm pleased the decision to close the unit has been supported," he said.

"No doubt there will be considerable pressure to re-open the Wyre Forest Birth Centre as soon as possible.

"I refuse to do this until I can be guaranteed that there are clear effective systems in operation being adhered to by every single member of staff.

"I am not prepared to take the chance of further avoidable tragedies."

He added: "Nothing we do can reverse mistakes that have been made in the past but we can all - as midwives, doctors or managers - learn from those mistakes."

The inquiry, carried out by an independent panel of four, also identified weaknesses in the trust management of the birth centre.

It found that while the trust and birth centre had structures and processes in place to ensure quality and safety of clinical care, these were not always effective.

"We're talking about broad criticism - there are no individuals named in the report - it's about systems and processes," Mr Rostill added.

"It's a readable report and is fairly hard hitting in some places but it is fair.

"It does talk about an entrenched attitude of people employed in Wyre Forest Birth Centre and difficulties between various groups of staff within the birth centre and other parts of the trust, mainly in Worcester," he added.

"It's very much an 'us' and 'them' situation at a unit that not only felt isolated but wanted to be isolated from the rest of the services in the county."

He added that in the past year positive steps had been taken to improve maternity services throughout the county.

"These actions cover a number of recommendations in the report which is hardly surprising since our own internal investigation also highlighted very similar issues," he said.

The birth centre was closed for deliveries on September 19, 2003, and the inquiry was launched in January.

The centre has remained open for post-natal and ante-natal care.