Ten years ago the hospital's pioneering maternity unit was forced to radically alter the way it set up the wards and provide extra training due to problems with understaffing.

The problems began to show three years earlier, when three nurses were found guilty of professional misconduct after Michelle Clark lost her son Benjamin.

The disciplinary committee of the midwives' governing body heard about management failures and understaffing.

The hospital initially denied the problems were anything to do with staff levels.

An external inquiry into the death of baby Isabelle Summers in 1998 found the individual rooms meant high-risk women could not be safely monitored during labour, particularly when nurses were working flat-out.

She was born dead because staff failed to spot signs of distress on a heart monitor.

Two other deaths in the unit, one just after it opened in 1995, ocurred in similar circumstances, but the hospital refused to accept it.

The hospital later changed the layout of its wards after its medical director said there was a significant risk of future problems.

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