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More maternity tragedies will occur unless rapid changes are made – report

Health Service Ombudsman Rob Behrens said the cases his office had heard were ‘extremely distressing’.

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A pregnant woman

Rapid changes must be made to England’s maternity services or more mothers and babies will be harmed, a damning report from the Health Service Ombudsman has concluded.

The new study, based on complaints and compensation payments made to women for poor care, found that mothers and babies are still being put at risk despite high-profile inquiries into services.

In 2015, the Morecambe Bay investigation found that serious failings led to the deaths of a mother and 11 babies, while systemic problems have also been found at Shrewsbury and Telford Hospital NHS Trust, leading to the deaths of around 200 babies and nine mothers, and also at East Kent Hospitals University NHS Trust.

A further inquiry into maternity care at Nottingham University Hospitals NHS Trust is currently being carried out by midwifery expert Donna Ockenden, who led the review into Shrewsbury.

In a new report, the Health Service Ombudsman’s office said that “if we do not start tackling these issues differently, there will be more tragedies”.

It pointed to the latest national NHS maternity survey which “shows a decline in people’s positive experiences of using maternity services”, adding that “women are not being listened to when they raise concerns about their pregnancies, babies, or their own health”.

It added: “Many of the issues are well-known, and there has been a significant investment of time, energy and money to improve maternity care.

“We welcome the £127 million funding boost the Government announced on 24 March 2022 for maternity services across England.

“We also appreciate the hard work of healthcare staff to improve them, especially when the NHS is under such significant pressure.

“We recognise that people working in maternity services want to provide high-quality care.

“Culture, systems and processes can get in the way of achieving that goal.

“But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make maternity services safer for everyone.”

The report includes the stories of women who have been affected by failures in maternity services.

One woman, Patricia Michael, from London, experienced bleeding during her pregnancy in January 2020.

Staff at Barts Health NHS Trust in London did no ultrasound scans to investigate the bleeding, leaving her anxious, and then did not properly explain her delivery options or induction of labour, the report said.

After Miss Michael had her son, her placenta did not deliver naturally as it should have done.

Staff removed it manually but did not do this in an operating theatre under anaesthetic, which meant they did not remove a large part of the placenta.

This did not follow the hospital trust’s policy. It also meant Miss Michael experienced pain and needed two more operations months later to remove the rest of the placenta.

Furthermore, staff did not explain or provide Miss Michael with information about a haematoma (a bruise caused by a pool of blood under the skin) on her baby’s head.

She said: “What happened to me should never be allowed to happen to anyone else. It was a traumatic experience that affected me deeply and still does.”

The report also detailed the story of Miss O, who was 21 weeks pregnant when she miscarried her daughter alone on the hospital floor at Barts Health NHS Trust in 2020.

The ombudsman found failings in the way her pain relief was managed, poor communication from staff about what to expect from a miscarriage at this stage of pregnancy, and missed opportunities to check the progress of miscarriage.

After she left the hospital, the mortuary service failed to tell her the date of her daughter’s funeral, and the baby was buried without the family’s knowledge.

The family were then given the wrong plot number for where their daughter was buried.

Health Service Ombudsman Rob Behrens said: “These cases are extremely distressing.

“People should be able to trust that the care they receive during what should be one of the happiest times of their lives will be safe, effective, and compassionate.

“Sadly, this is often not the case. Failures in maternity care can have a devastating impact on women, their babies, and their families, and that impact can be long-lasting.

“The fact that we are still seeing the same mistakes over and over again shows that lessons are not being learned. This is unacceptable. There needs to be significant improvements and change.”

An NHS spokesperson said: “Providing safe and personalised maternity care to all women before, during and after their pregnancy is vitally important, and it is clear there have been severe failings in the care that women and families have received, when they should have been protected and cared for by our services.

“To ensure that we provide the best possible services for mothers, babies and their families, we are investing £165m annually to grow our workforce, strengthen leadership and improve culture, while continuing to work closely with NHS trusts and our partners to make necessary improvements.”

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