THE UK's nursing regulator's handling of the Morecambe Bay maternity cases was deeply flawed - and it let down the families of those who lost loved ones, a damning report has stated.

The shocking review said at least one baby died and there were two further serious untoward incidents at the hands of midwives who continued to work at Barrow's hospital after 2013 while they were under investigation by the Nursing and Midwifery Council (NMC).

The controversial document, published today, concluded the NMC also ignored urgent warnings from Cumbria Police despite investigators repeatedly contacting them over the issue in a bid to protect the public.

Lengthy delays in bringing midwives before a fitness-to-practice panel were unacceptable, it went on, with the case of Dalton baby Joshua Titcombe taking eight years between the first referral and disgraced midwife Lindsey Biggs being finally struck off.

And more should have been done to engage with families, many of whom had lost babies in avoidable circumstances, it found.

Harry Cayton, chief executive of the Professional Standards Authority, which carried out the review, said: "What happened at Furness General Hospital remains shocking, and the tragic deaths of babies and mothers should never have happened.

"The findings in the review we are publishing today show that the response of the NMC was inadequate.

"Although the NMC has made good progress with its technical handling of complaints and concerns, there remain cultural problems which it must remedy in order for the public to have confidence in its ability to protect them from harm."

NMC chief executive Jackie Smith, who announced her resignation on Monday, said she fully accepted the findings of the report before issuing an apology to all those affected by the actions of her organisation.

In a statement she said: "The NMC’s approach to the Morecambe Bay cases – in particular the way we communicated with the families – was unacceptable and I am truly sorry for this.

"We take the findings of this review extremely seriously and we’re committed to improving the way we communicate with families, witnesses and all those involved in the fitness-to-practise process."

Ms Smith had worked within the NMC since 2010. In the review she admitted the regulator 'was not in a state to address the concerns that arose in respect of Furness General Hospital'.

Record keeping within the NMC was described as 'very poor', the report found, a fact exacerbated by a high turnover of staff.

Ms Smith added: "Since 2014 we’ve made significant changes to improve the way we work and as the report recognises, we’re now a very different organisation.

"The changes we’ve made puts vulnerable witnesses and families affected by failings in care at the heart of our work. But we know that there is much more to do."

Today's review, carried out by the Professional Standards Authority, was launched last year by health minister Jeremy Hunt to look into the way the NMC handled the cases of midwives involved in the scandal as well as its behaviour towards the victims and their families.

It followed the conclusion of the Morecambe Bay Report which found 11 babies and one mother had died as a result of a 'lethal mix' of poor standards in care and culture at Furness General Hospital between 2004 and 2013.

But the PSA investigation, which examined 51 cases in total and 30 named individuals, found evidence that more babies were likely to have been harmed after 2013.

Cumbria Police, which began a criminal investigation into deaths and allegations of collusion within the maternity unit at FGH in 2012, referred 22 cases to the NMC.

The report states: "In 2012 Cumbria Police provided the NMC with a list of cases where there were concerns about the care of patients.

"The NMC appears to have taken no action on the list for almost two years when, as the police told us the point of providing the information was to enable the NMC to consider whether urgent action ought to be taken."

Bereaved Dalton dad James Titcombe supplied a written chronology of the care his wife and son received in 2008 to the NMC.

But this document, the PSA found, appeared to have been lost by the NMC 'at an early stage'.

But despite this, NMC chief executive Jackie Smith told the secretary of state for health in a formal letter that the misplaced document had been given 'careful consideration' before a fitness to practice hearing relating to the midwives involved in 2016.

A spokesman for the NMC denied it had mislead the secretary of state over the whereabouts of the document.

Instead, they said simply: "Our wording in some correspondence could have been clearer."