After an eye-opening documentary from BBC Panorama this week investigated the pressure on maternity services, Adele Wilde, Solicitor in our Clinical Negligence team, discusses the issues raised and how the traumatic stories told from families and midwives alike are worrying amidst one of the biggest birth injury scandals involving the NHS.
I have represented many families who have sadly suffered a stillbirth or neonatal death of their baby as a result of inadequate care. I have heard the heartache and devastation it causes, and my heart goes out to all the families affected by the treatment provided by Gloucestershire Hospitals NHS Trust and any family who has suffered the devastation of the death of their baby.
BBC Panorama spoke with three bereaved families whose lives had been shattered as a result of maternity care provided to them by Gloucestershire Hospitals NHS Trust. The families spoke with raw emotion as they set out what had happened during what should have been one of the happiest moments in their lives.
Laura White attended the midwife-led Cheltenham Birth Centre when pregnant with her sixth baby, Jasper, in 2019. Laura had a number of health issues but had not been told she was high risk (if she had, she explained she would have gone straight to the hospital). Jasper was born quickly, but within a few minutes his health started to deteriorate. Laura recalled how there was no urgency in escalating her baby’s worsening condition. It took 50 minutes before a priority call was made for an ambulance to transfer him to a specialist hospital. Sadly, Jasper died at 11 hours of age.
Laura Harvey, a first-time mother attended the same Birth Centre in May 2020 when she was 41 weeks pregnant. She had been in labour for six hours and had some vaginal bleeding. She should have been transferred to a specialised unit at this point where doctors could have taken over her care. However, this did not happen. It was only on the third occasion of her requesting an ambulance that one was called. Baby Margot was delivered at the birth centre and transferred by ambulance to Gloucestershire Hospitals NHS Trust before being transferred to Bristol for specialist care later that day. Sadly, she passed away in her mother’s arms, aged three days old.
The Trust carried out an investigation into both the death of Jasper and Margot. These identified that an ambulance should have been called earlier in both cases and the two midwives involved in the treatment of both babies are now being investigated by the Nursing and Midwifery Council.
In March 2021, Rana was 39 weeks pregnant with her second child. She attended Royal Gloucester Hospital for a routine check-up. Rana struggled with English, but no translation services were used. An induction of labour was started. When her husband arrived at hospital, he was told that his daughter had been delivered but that his wife had haemorrhaged. There was a delay of over 30 minutes in calling for specialist help and a delay of almost an hour in giving Rana the first transfusion. Devastatingly, Rana did not survive and her husband was left to raise his young family alone. Gloucestershire Hospitals NHS Trust admitted full responsibility for Rana’s death.
Although maternal deaths are rare, the Panorama investigation identified that between 2018-2022 there were 7 maternal deaths at Gloucestershire Hospitals NHS Trust, which is almost twice the national average for that period. The investigations identified interpretation services were not being used and there was no ongoing risk assessment of pregnant women.
The investigation showed that midwives are under unprecedented pressure. Midwives are not being listened to, there are not enough staff, they are over-stretched and, as a result, mothers and babies being put at risk.
Panorama heard from a former midwife at the Trust who raised concerns about the treatment provided by the two midwives caring for Laura White her at the birth centre, but her concerns were dismissed, no investigation took place and no changes to practice were made.
The same midwife raised concerns about the treatment provided during baby Margot’s delivery. This was the second baby to pass away in less than a year under their care as a result of a delay in escalating treatment. Shockingly, her concerns were again dismissed and no investigations took place, no lessons were learnt. This was the last shift the midwife worked as she felt unheard and helpless.
The midwives described how short staffing impacts their wellbeing; they are spread so thin that they cannot provide safe care. They go home at the end of a long and intense shift feeling exhausted. One midwife explained they live with the constant anxiety not knowing whether there will be enough staff to be able to deal with things safely if things do go wrong. A poignant moment in the documentary for me was when an exhausted and depleted midwife asked: “would it take a midwife to take her own life because of the pressure they are under for something to change?”
The helplessness and desperation the midwife described feeling knowing that more staff could have made a difference to one baby passing away is clear to hear. However, the impact on the bereaved families is unimaginable.
Maternity services in general
In the last 10 years, there have been a number of national maternity scandals. Inquiries and investigations have taken place and another is currently underway in Nottingham University Hospitals NHS Trust. There have been similar themes running through all the investigations. However, it does not appear as though lessons are being learnt on a national level.
The families I represent often talk about wanting to ensure that lessons are learnt that no other family has to go through the same devastation that they have. They want a change in in practices, additional learning and training and to make sure that their baby’s death makes a difference to future parents. It is clear to me that the midwives who featured on the programme also want things to change, so that they can provide safe levels of care.
Sadly, this will not be the end of the investigations into maternity failings. Donna Ockenden is currently leading a panel to investigate the care provided at Nottingham University Hospital Trust. It is hoped that through these investigations and recommendations, the standard of maternity care will improve. However, many midwives and clinicians are joining bereaved families in calling for a national inquiry so that lessons can be learnt and changes made on a bigger scale.
How can we help?
If you have experienced something similar to the stories featured and would like to find out more about how to make a birth injury claim, you can find out more on our dedicated birth injury page. Our expert solicitors are here to help.