The Birth Trauma Inquiry: a further demand for safer maternity care

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Today (13th May 2024), the country’s first parliamentary inquiry into birth trauma has been released. The headline? Good maternity care ‘is the exception rather than the rule’.

Here, medical negligence Senior Associate, Charlotte Tracy, looks at the inquiry in more detail.

The Birth Trauma Inquiry

1,300 women gave evidence to the inquiry. The report contains disturbing stories, including:

  • A woman reported extreme pain and was recorded as an ‘anxious mother’ when she was bleeding internally, related to a potentially fatal complication.
  • A woman was told by a consultant, when she lost her first twin at 19 weeks, that the baby had been dead “a long time anyway” and she should “stop stressing” so they could try to save the other baby, who sadly later died as well.
  • A woman raised concerns that her baby was jaundiced and was recorded as an overly anxious mother. Once her husband intervened and the baby was diagnosed as jaundiced, the page in the notes was torn out.
  • Women were left to lie in their own blood, urine and excrement; some were berated by midwives for having soiled themselves.
  • A baby suffered a hypoxic brain injury at birth due to negligence, which the hospital covered up (eventually resulting in a claim for substantial damages).
  • There was a postcode lottery in terms of mental health support available.

The all-party inquiry is led by Conservative MP, Theo Clarke, and Labour MP, Rosie Duffield. Ms Clarke broke down when describing, in the Commons, her own traumatic birth experience in 2022, which left her feeling she was going to die.

A backdrop of maternity scandals

This inquiry follows a catalogue of maternity scandals, including:

    • London North West University Healthcare NHS Trust: this Trust’s maternity service was investigated twice about the deaths of 10 women between April 2002 and April 2005. In 2021 the CQC found poor culture and bullying in the maternity service, and there had been eight baby deaths in a five-week period between July and August 2020.
    • University Hospitals of Morecambe Bay NHS Trust: the Kirkup Report was the outcome of an investigation into events between January 2004 and June 2013 at this Trust. It found that failings in the maternity service led to the deaths of 11 babies and one mother. The report said that the response to potentially fatal incidents was ‘grossly deficient, with repeated failure to investigate properly and learn lessons’. At Morecambe Bay, there was a group of midwives who would seek a ‘normal’ delivery at any cost and refused to call doctors when needed.
    • East Kent Hospitals University NHS Foundation Trust: In April 2021, this Trust pleaded guilty to failing to provide safe care after a rare CQC prosecution, the first of its kind. This arose out of the avoidable death of baby Harry Richford.
    • Nottingham University Hospitals NHS Trust: a report found that 46 babies suffered brain damage and 19 were stillborn at Nottingham University Hospitals between 2010 and 2020. It says managers ‘failed to properly investigate concerns and altered reports to take the blame away from the maternity unit’.
    • Shrewsbury and Telford Hospital NHS Trust (see below)

Today’s report sets out in its key themes: “The overwhelming narrative was one of distress at being neglected, ignored or belittled at a time when women were at their most vulnerable.” In an episode of Barcan+Kirby Bitesize, I spoke to perinatal psychotherapist, Anna McGuire, about how not being believed can compound birth trauma and maternal mental ill health. One point of learning from today’s report is that there should not be a default assumption that women are being over-anxious or over-dramatic.

Video | Barcan+Kirby Bitesize: birth trauma and maternity care

Our blog in 2022 discusses the final Ockenden report into the scandal at Shrewsbury & Telford, where failures contributed to the deaths of 201 babies and nine mothers, as well as numerous serious injuries. That report set out 15 key immediate actions for improvement, the first of which was financing a safe maternity service. That was an issue highlighted in BBC Panorama’s January 2024 programme. Shortages risk missing opportunities for escalation or delaying induction of labour, which led in one case to a baby’s death. It was also highlighted that this takes a huge toll on midwives’ health and wellbeing.

Donna Ockenden commented, in respect of today’s inquiry report, that she had previously given the Government a “clear blueprint and roadmap” for maternity services and “progress has been far too slow”.

The report calls on the Government to publish a National Maternity Improvement Strategy, led by a new Maternity Commissioner. Many of the recommendations we have heard before, including: recruiting, training and retaining more midwives; wider and more reliable access to mental health services; tackling inequalities in maternity care among ethnic minorities; and more informed choice for mothers and ensuring respect of that choice. There is also a suggestion to extend the time limit for bringing a claim for compensation (known as the ‘limitation period’) from three to five years.

The Government and the NHS have committed to producing a comprehensive strategy to improve maternity services. The next steps in the strategy should be announced in the coming months.


Campaigners have called for an inquiry for a long time, after repeated requests for improvement to services following a list of scandals. Although it is probably not surprising to those so devastatingly impacted by poor maternity care, the stories in this report must seem like another blow. I would back calls for urgency in publishing a strategy and ensuring safe and equitable access to maternity care for all.

Useful resources for support

Further information

If you have experienced a traumatic birth, if you or your child have suffered an injury during birth, or if you have any concerns about your maternity experience, our medical negligence solicitors may be able to help.

Call our friendly team on 0117 325 2929 or complete our enquiry form.


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