Avoidable deaths? Programme investigates ‘inadequate’ maternity care at Gloucestershire Hospitals

A BBC Panorama programme that aired on Monday 29^th January 2024 has highlighted severe failings in care at Gloucestershire Hospitals NHS Foundation Trust. Independent regulator, the Care Quality Commission (CQC), has repeatedly issued warnings about the standard of maternity care at the hospitals.

We are always sorry to read stories of poor maternity care from around the UK, but it is particularly difficult to hear about the deaths of mothers and babies within the community of the South West, which our firm calls home.

So, what has gone wrong, and what is the Trust doing to make improvements?

‘Midwives under Pressure’

In last night’s documentary, whistleblowers shared their experiences of working at Gloucestershire Hospitals, including details about the deaths of mothers and babies, understaffing and a feeling that maternity staff and the wider department had failed to learn from their mistakes.

Ahead of the programme, the BBC reported that whistleblowers alleged poor culture and staff shortages led to avoidable baby deaths. This included allegations that a newborn baby had died after the Trust failed to take action against two staff members; concerns had been raised by their colleagues after another baby had died months earlier. Both the midwives in question are subject to ongoing Nursing and Midwifery Council investigation.

This programme follows reports that Gloucestershire Hospitals NHS Foundation Trust had been re-issued with a warning notice about safeguarding training and maternity care, despite meeting some requirements after two warning notices for surgical and maternity services were previously issued by the CQC after inspections in April 2022.

Leading up to the programme airing, the BBC revealed that its calculations suggest “maternal deaths [at the Trust] are almost double the national average”. It should be noted that the Trust released a statement on 26^th January 2024 to say that the figures have been independently reviewed by national experts on maternal and neonatal deaths, MBRRACE-UK, and the data at Gloucestershire is in line with the national average and not statistically significantly differently from the UK in general. More information on how that data is collected and analysed appears here. In the article, the BBC said: “Seven women under the care of [the Trust] died while pregnant or shortly after giving birth – between 2018 and 2022 – about twice the UK average for maternal deaths. The trust says not all the deaths in that period were attributable to its care.” It is therefore important to note there are differing views on the impact of the adequacy of care on the maternal death rate at the Trust.

Inspection into maternity care at Gloucestershire Hospitals

The CQC’s inspections (prompted by whistleblowers reporting bullying, racial discrimination, poor leadership and a blame culture) in April 2022 found 11 serious patient safety incidents called ‘never events’ at the hospital, relating to surgical and maternity care in the 2021/2022 period. The Trust had reported having the highest number of never events in England in April 2021, and the highest in South England in the period to 2022.

The inspections highlighted that staff were not receiving full safety training and incidents were not investigated quickly or fully, meaning that the opportunity to prevent future incidents was delayed, putting patients at risk. For example, staff could not tell the CQC what learning there had been from a never event in the maternity department at the end of 2021. Staff shortages were cited as a factor across the report on maternity services; for example, maternity staff wanted to learn and improve but staff shortages meant they could not complete training. The report describes ‘severe’ midwifery shortages with some places being filled by registered nurses instead. Panorama highlighted the toll the shortages took on midwives’ physical and mental health. One midwife said they had been told to stop raising safety incidents relating to staff shortages as nothing could be done. Shortages mean missing chances for escalation, risking the lives of mothers and babies. They can also lead to delayed induction which, in one reported case, caused a baby’s death.

The inspections led to the Trust’s overall rating dropping from ‘good’ to ‘requires improvement’.

Following the 2022 inspections, improvements were made: in November 2023, CQC inspectors noted that risks to women were identified and acted on, and waiting times in maternity triage had improved. However, the regulator issued a further warning to make sure suitable safeguarding training was provided for all staff and recommended that incidents should be investigated in a more timely way to reduce the risk of future events.

At the end of March 2023, there were still 215 incidents waiting to be investigated.

The impact of substandard maternity care

Unfortunately, these findings aren’t isolated to Gloucestershire Hospitals NHS Foundation Trust. The 2022 Maternity Survey (analysed by us here) highlighted some shocking findings regarding birth and maternity culture in England. One of the key themes from the data is that many mothers didn’t feel heard: 1 in 4 said the midwife or midwifery team did not always listen to them and 1 in 5 said their concerns during labour or birth were not taken seriously. A worrying picture, and one that is reflected in the stories in last night’s Panorama. Laura Harvey, who sadly lost her daughter Margot in May 2020, experienced bleeding but was reassured by her first midwife. The issue of bleeding was not handed over to the second midwife on shift. Laura began to feel something was wrong and asked twice to be transferred from the Cheltenham Birth Centre (meant for women with low-risk pregnancies, but with no emergency facilities) to Gloucestershire Royal Hospital obstetrics unit, 30 minutes away. Only after her third request did paramedics arrive. A third midwife involved is one of the whistleblowers interviewed by Panorama. Margot was sadly born in poor condition and treated in specialist neonatal care before passing away.

Our maternity and birth injury solicitors have previously shared concerns about the standard of maternity care in the UK, including the disappointing findings from an MBRRACE-UK report which looked at how women from minoritised ethnic groups are more likely to die or suffer injury in childbirth and the Ockenden report into the maternity scandal at Shrewsbury and Telford Hospital NHS Trust.

Patient safety incidents can arise out of a wide variety of issues, such as staff shortages (leading to fatigue and overwhelm), lack of or incomplete training, failure to learn lessons from previous incidents, lack of accountability or poor culture. These can have serious repercussions for both mothers and babies; something our birth injury solicitors see far too often. We recently helped a first-time mother claim compensation after a hospital misdiagnosed her perineal tear as the result of substandard care. Perineal tears are not uncommon. However, because it was incorrectly categorised at the time of repair, our client was left with continence issues and a psychological disorder.

If incidents are not investigated, the risk of them happening again and putting mothers in danger is high. In the final Ockenden report in March 2022, it was found that at least 201 babies would have survived with better care and there were 1,592 incidents of poor care over ‘two decades of repeated failures’. It is incredibly sad to think that women and babies have lost their lives due to human error, but worse still for it to be found to be a result of medical professionals not learning from previous mistakes.

The future of maternity care

We hope, of course, that the standard of maternity care significantly improves at Gloucestershire Hospitals. If not, their CQC rating could decrease further, leaving expectant women in the area with limited options when it comes to planning their birth.

The Trust’s January 2024 statement said they have increased the number of midwives, and numbers in leadership roles, along with implementing a number of safety improvements. We hope there is continued accountability, reflection and improvement such that patients in our local South West area can access safe maternity care, and feel reassured so they can enjoy the milestone of becoming a new parent.

On a broader scale, the standard of maternity care across the UK remains a concern. The Royal College of Midwives has reported that England’s NHS is “2,000 midwives short of the numbers needed” so, without drastic action, other hospitals are not only at risk of being under-staffed but more women and babies may suffer avoidable harm. Charity Baby Lifeline has commented to the BBC that the budget for maternity services is not increasing in line with that for other services. The Ockenden report’s first immediate and essential recommendation was to finance a safe maternity workforce. We would support that as a key priority to uphold patient safety and the wellbeing of midwives and obstetric doctors.

Further information

As medical negligence solicitors, it is heartbreaking to see the repercussions of maternity failings and we will continue to campaign for change. If you or a loved one have suffered as the result of sub-standard maternity care, we are here to help. For support and advice, call us on 0117 325 2929 or fill out our online enquiry form.

Further support relating to pregnancy and baby loss can be found below:

• Sands
• Tommy’s
• Miscarriage Association