England’s Health Ombudsman has warned that women and babies are being put at risk after a worrying rise in the number of investigations about maternity care.
The Parliamentary and Health Service Ombudsman (PHSO) is urging the Government and NHS leaders to learn from the mistakes being made and take action to protect more families from harm.
In 2023/24 (1 April – 31 March) the PHSO investigated 87% more cases (28) about maternity care than the previous year (15). These are all cases which have already been investigated by the NHS and where they failed to address concerns. The Ombudsman recently closed a case in which it found a catalogue of failings by a hospital led to the death of a baby girl who was stillborn in December 2018.
In the cases investigated issues identified included delays to treating infection and carrying out an MRI scan, failing to manage an epidural during a caesarean, and lack of consent for a procedure. Since April 2020, PHSO has carried out 80 detailed investigations related to failings in maternity care. Investigations concluded in 2023/24 account for over a third of these.
During that time the number of investigations upheld or partly upheld has also increased.
In March 2023, PHSO published a report about issues in maternity services. Common problems highlighted in that report include poor communication, and failings relating to diagnosis, aftercare, and mental health support.
Rebecca Hilsenrath, Parliamentary and Health Service Ombudsman, said:
“The rise in maternity investigations and the number of complaints being upheld over the last four years give rise to real cause for concern. It suggests that despite considerable investment in maternity care and well-publicised reviews into service failings, things are far from improving.
“There have been successive inquiries and reports into maternity care and no real evidence of change. We need to see lessons being learned. Our 2023 report found the safety and wellbeing of women is being put at risk due to the same mistakes being repeated.
“We know that there are brilliant practitioners out there. But when maternity services fail, families are left with trauma and tragedy. The NHS needs to take steps to share good practice and change what isn’t working.”
In the recently upheld case, 33-year-old Carly Hardwidge, who lives in Chippenham, told clinicians seven times that she couldn’t feel her baby moving. She also repeatedly told midwives she was experiencing pain, contractions, water leakage and had blood-stained discharge.
PHSO found staff at Royal United Hospitals Bath NHS Foundation Trust failed to properly investigate Carly’s concerns or refer her to an obstetrician on multiple occasions.
Rebecca Hilsenrath continued:
“The catalogue of failings by the Trust in this case is truly shocking and it led to the devastating loss of a baby.
“Once again, we see a patient’s concerns dismissed and not taken seriously. The lack of continuity of care meant nobody took a holistic view of what was happening. Ultimately, this led to the tragic avoidable death of a baby girl.”
Having previously had two miscarriages and pre-eclampsia, Carly should have been graded as high risk and placed under the care of a consultant.
She should have been referred to a senior consultant as early as September 2018 when she reported concerns about fluid loss for a third time. Carly should also have been referred to a consultant when she reported lack of movement for a second time in November.
These serious failings led to her daughter, Seren Browne, being stillborn. PHSO’s obstetrics adviser said the likely cause of death was infection caused by a slow leak of the water surrounding Seren.
Carly, who has four children, but says she will always be a mother-of-five, said:
“I was never listened to or taken seriously by the hospital staff. It has affected my mental health and still massively affects me, my partner Haydn, and our other children.
“We didn’t lose a baby, we lost a whole life; her first steps, her first words, her first day at school, which would have been last year. Every day there is a constant reminder of Seren and what might have been. There are so many what-if questions – what would she look like now, what would she be doing?
“For years I blamed myself. I was the one who carried her. I’m the one who was meant to keep her safe. Now I have it on paper that if I had been listened to my daughter would be here today. Seren would be playing in the park, eating ice cream and causing chaos with her siblings. Instead, she’s at home in an urn on the shelf.
“If more people were listened to and taken seriously, this would not keep happening. That’s where I get my strength from, despite everything, I fight every day for justice for my daughter.”
Alongside the clinical failings, staff’s attitude and behaviour fell well below professional standards – an issue previously highlighted in national reviews of maternity services. The Trust’s bereavement care was also below what is expected.
The Ombudsman recommended that the Trust acknowledge its failings, apologise, and set out what it will do to prevent the same mistakes happening again.
The Trust was also told to pay £1,000 to recognise the impact the failings in bereavement care and complaint handling have had on the family. This amount only relates to those issues. The failings in antenatal care have been referred by the Trust to NHS Resolution to agree a compensation award with Carly.
A spokesperson for the Royal United Hospitals, Bath, said:
“We are deeply sorry for the tragic loss and emotional distress experienced by the family.
“We apologise for the failings identified and fully accept the recommendations of the Parliamentary Health Service Ombudsman.
“We all strive to provide excellent and safe care for women, birthing people and their babies and when harm happens, we spend time reflecting on and learning from what we could have done differently.
“We have made changes in response to this case, including training in relation to carrying out risk assessments and identifying when to refer to consultants and embedding a communication and escalation tool kit.”