A furious council leader has taken the unprecedented step of issuing a public three page letter to the bosses in charge of hospitals where mums were failed in maternity wards.
Andrew Morgan turned up at the meeting of the Cwm Taf health board on Thursday, despite being told he could not speak, and called for senior managers to be held responsible for the scandal.
The meeting was being held to discuss a report into why a consultant midwife's damning first investigation into the problems at the Royal Glamorgan Hospital and Prince Charles Hospital were not more widely circulated and acted on.
The level of stillbirths exposed by the midwife in September 2018, which painted a picture of a failing, understaffed service lacking basic procedures, was not made public until May the following year.
Rhondda Cynon Taf leader Mr Morgan said it was scandalous if mums and babies were put at risk because of a report had been "suppressed".
The Labour politician said: "If senior executives of this health board had an independent report which was commissioned by them and they did nothing about it - they did not share it with the wider health board members and, to my view, they suppressed that report and didn't act upon it then that's just scandalous.
"During that period people could have potentially been put at risk and individuals should answer for what has happened."
At the meeting at Ynysmeurig House in Abercynon , board members were able to put questions and concerns to Independent Governance Advisor, Steve Combe, who carried out a report into how the initial report had been handled.
The report highlighted systematic failures in clinical care, inadequate reporting of incidents and missed opportunities for improvement. It also raised staff concerns about a "punitive culture of blame" within the units. However it was not shared with board members or their committees.
At the meeting Mr Combe claimed that, according to his findings, the report wasn't purposely ignored but said "there was a lot going on at the same time".
Coun Morgan said the senior executive team must be held to account for what's happened.
"The staff who raised this initially should be commended," he said.
"They have obviously lifted the lid on something that has been going on for quite some time. Personally I feel very upset about it.
"I I have met with individuals - several individuals have come to my office to have planned meetings with me hearing absolutely horrific, distressing stories about what they've gone through.
"I've had various emails with photos around injuries people have had during really bad treatment.
"I've heard horrific stories about how mothers were told that they had lost their child, and then were put back on a ward with other mothers who had just had their babies and had their babies with them.
"Really distressing stories where there was no compassion, no thought for those individuals and I think sitting through some of those meetings I've had has been quite horrific and it's for that reason I've taken the decision to come here today.
"I wanted to speak to the board, but I was told I wasn't able to due because the procedures don't allow so I did put a three page letter to each board member at the start of the meeting exactly telling them what I think."
Many board members expressed their concern for the situation at the meeting, but Mr Combe suggested the report wasn't hidden from board members with intent.
Instead, it appears to have been put to one side while other matters were dealt with.
Speaking at the meeting, he said: "There were a number of staff on sick leave.
"At the same time the health board looked to take the Bridgend population on.
"There was a lot going on at the same time.
"There was a report from Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives to come through."
As the meeting concluded it was decided that more work would be done before the next meeting, scheduled for the end of January, to answer further questions about how the report appeared to go missed.
As the meeting was brought to a close chair Marcus Longley thanked the staff involved in putting together the Secondee Consultant Midwife report for raising such issues in the first place.
He said "urgent action" now needs to be taken to ensure something like this never happens again.
"It is very distressing at the least," he said.
"Many of us feel quite angry and upset that this evidence can be heard.
"It is clear we accept all the responsibilities.
"It is clear we now think we need to take urgent action. "