review team found that 40% of the stillbirth reviewed by us did not have a trust investigation. in the same period, 43% of the neonatal deaths reviewed by us had not had a trust investigation. you will all know that without investigation, we cannot understand what may have gone wrong and we cannot learn. without learning, we cannot improve maternity care for the future. i would now like to talk you through a timeline of some events and clearly this is described in greater detail in the report. today, and with permission of our parents, i would first like to tell you about 0livia, who died shortly after her birth in 2002. her mother repeatedly tried to raise concerns about feelings at the