According to the CQC many of the maternity failings are becoming more widespread.  Its review of 131 units across the NHS highlighted issues with staffing, buildings, equipment, and the way safety was managed, warning preventable harm was at risk of becoming “normalised”.

The CQC’s 16-month investigation targeted maternity units not inspected and rated since March 2021 – about two-thirds of the total and mostly those it had been least worried about.

The review found examples of good practice but expressed concern about:

• staffing shortages, with nurses fresh out of university taking on tasks better suited to more senior midwives and doctors;

• problems with equipment, including call bells not working and poor pain management;

• delays to emergency caesareans, because operating theatres were unavailable;

• inconsistencies in the way safety incidents were monitored and recorded, including major emergencies such as significant loss of blood and internal injuries recorded as causing low or no harm;

• bad leadership and management creating blame cultures and low morale;

• triage problems, with women facing delays being assessed and not being prioritised properly; and

• evidence of discrimination against people belonging to ethnic minorities, including a lack of support for women whose first language was not English

Overall, 48% were rated as inadequate or requiring improvement with around a quarter receiving a lower overall rating than when last inspected. On the single issue of safety, 65% were judged to be failing.

Details have also emerged about the findings of a separate investigation into two of those units that were judged as inadequate – the Royal Derby Hospital and Queen’s Hospital, which are run by University Hospitals of Derby and Burton NHS Trust.

University Hospitals of Derby and Burton NHS Foundation Trust has said it “…could and should have done better…” after a review into more than 150 perinatal (baby) deaths found “care issues” which may have affected losses of life.

Perinatal deaths include babies from the start of pregnancy up to the age of one, largely made up of stillbirths and complications during pregnancy and birth.

The report detailed 168 perinatal deaths which occurred at the trust between January 2020 and March 2023.  99 related to stillborn babies, 56 neonatal baby deaths (in the first 28 days of life) and 13 “late fetal losses”.

Of the 168, 11 babies were born at the Trust but died elsewhere after being transferred, and the report focussed on the remaining 157.

The report also found 24 families, all in 2020, were not contacted to take part in reviews relating to their baby’s death.

The report noted that “Whilst there are many opportunities for sharing learning across maternity services the learning is not necessarily embedded into practice.”

“This is reflected in the recurrent themes identified in this report, including fetal monitoring interpretation, women reporting reduced fetal movements and subsequent care, documentation, and communication issues.”

CQC specialist care director Nicola Wise said maternity care needed “urgent reform” as preventable harm was at risk of becoming “normalised”

“Failings uncovered in recent high-profile investigations are not isolated to just a handful of individual Trusts,” she said.

Sandra Igwe, Chief Executive of the Motherhood Group, which works to support black mothers, said maternity units were “notorious” for how they treat black women and families.

“We are now seeing that maybe maternity care isn’t safe for anybody but especially for those who are disproportionality affected,” she said.

Sadly, there have been multiple reports like this over the past decade and despite these recurrent themes there is lack of meaningful change.

There needs to be a “just culture” in all healthcare – particularly maternity care – where women are listened to and are heard as well as being involved and informed.  

To achieve that and to reduce avoidable harm and associated trauma, there needs to be a commitment to improving maternity care in the UK to drive much needed consistent improvement and accountability in maternity care that has so far been lacking.

The question is: what is it going to take to finally galvanise that change?

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