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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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Former Labour Health Secretary Alan Milburn, who is heading it up, said when the inquiry launched that he would approach the issue "with sensitivity".