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Withdrawing “cold turkey” from opioids while pregnant increases the risk of preterm birth, low birth weight, and stillbirth.

The closure of these facilities exacerbates maternal health disparities by forcing pregnant women to travel further, increasing the risk of preterm births, low birth weights, and maternal mortality.

The inquiry ruled "defects" within the system contributed to each death, including that there was a "lack of an effective means" to highlight risks in one of the pregnancies and that midwives had no guidance to assess preterm labour symptoms.

His family called the Princess Royal Maternity Hospital in Glasgow because mum Nadine Rooney was experiencing "agony back pains" – but the midwife triaging the call didn't spot it as a sign of preterm labour for her at 27 weeks.

This was despite Ms Rooney being considered a high risk pregnancy, having previously given birth to a preterm baby and being a smoker.