Medical Negligence

Statutory Inquiry now needed as Birth Trauma report reveals ‘shockingly poor care’ across UK’s maternity services


Maria Repanos

Head of Clinical Negligence (Manchester)

5 min read time
13 May 2024

Hudgell Solicitors has renewed its call for a Statutory Inquiry into the standard of Britain’s maternity services as a new report today highlighted the ‘shockingly poor quality’ across the UK.

An All-Party Parliamentary Group (APPG) inquiry into the birth trauma experiences of hundreds of women found good care for pregnant women to be ‘the exception rather than the rule’, with ‘poor care all too frequently tolerated as normal’.

The Inquiry considered more than 1,300 submissions from families, together with other relevant parties and was established to identify common features in maternity care that contribute to birth trauma.

Those who gave evidence overwhelmingly spoke of the ‘distress at being neglected, ignored or belittled at a time when women were at their most vulnerable’.

The Times today says the report details how new mothers recalled being left in blood-soaked sheets for hours, with one dismissed as being an ‘anxious mother’ when her baby then later died from complications she had been warned about.

The Inquiry has made 12 recommendations for action, including the appointment of a new maternity commissioner to report to the Prime Minister.

The Government and the NHS have committed to producing a comprehensive strategy for maternity services following today’s report publication, and Hudgell Solicitors says that now needs to include holding a Statutory Inquiry to investigate the ‘root causes of systemic failings’.

Our lawyers contributed to the Inquiry by making our own submission, detailing observations of birth injury solicitors on the impact of poor maternity care. The submission included statements on behalf of more than 20 women who our legal team has supported in recent times.

‘Issues relate to funding, training, management and accountability’

Medical Negligence solicitor, Maria Repanos said;

We are currently in a situation where there are multiple individual inquiries being carried out in relation to maternity services at various NHS Trusts across the UK due to issues ranging from concerning numbers of birth injuries or loss of life to inappropriate standards of care, clear lack of training and poor communication,”

These investigations and inquiries are, of course, all significant on their own merit, however we have not yet seen the impact required where positive change has been effected. Sadly, standards are not improving quickly enough.

There are a number of maternity services in the UK failing woefully as a result of issues relating to funding, training, management and accountability. These issues need to be reviewed nationwide across all existing services to identify the root causes of systemic failings.

As of last October the Care Quality Commission (CQC) rated 65% of maternity services in England as either ‘inadequate’ or ‘requires improvement’ in relation to the safety of care.

We firmly believe that the NHS’s failure to improve maternity safety is so startling that a statutory inquiry is imperative to ensure that women, babies and their families no longer come to any avoidable harm. This is more likely to bring about much-needed change.

The report comes after Conservative MP Theo Clarke, who thought she was going to die when giving birth to her daughter, Arabella, in 2022, launched a parliamentary inquiry. She described some mothers’ testimony to the inquiry as ‘horrific’.

The number of women who die during pregnancy or soon after has risen to its highest level in 20 years, figures released this year show, while British infants are more likely to die before their first birthday than in most other developed countries.

The APPG on Birth Trauma calls on the Government to publish a National Maternity Improvement Strategy, led by a new Maternity Commissioner  who will report to the Prime Minister, which will outline ways to;

  • Recruit, train and retrain more midwives to ensure safe levels of staffing in maternity services and provide mandatory training on trauma-informed care.
  • Provide universal access to specialist maternal mental health services across the UK, to end the postcode lottery.
  • Offer a separate 6-week check post-delivery with a GP for all mothers, which includes separate questions for the mother’s physical and mental health of the baby.
  • Rollout and implement by sufficient training, the OASI (obstetric and anal sphincter injury) care bundle to all hospital trusts to reduce the risk of injuries in childbirth.
  • Oversee the national rollout of standardised post-birth services, such as Birth Reflections, to give all mothers a safe space to speak about their experiences in childbirth.
  • Ensure better education for women on birth choices. All NHS Trusts should offer antenatal classes. Risks should be discussed during both antenatal classes and at the 34-week antenatal check with a midwife to ensure informed consent.
  • Respect the mother’s choices about giving birth, and their access to pain relief and keep mothers together with their babies as much as possible
  • Provide support for fathers and ensure the nominated birth partner is continuously informed and updated during labour and post-delivery.
  • Provide better continuity of care and digitise the mother’s health records to improve communication between primary and secondary health care pathways. This should include the integration of different IT systems to ensure notes are always shared.
  • Extend the time limit for medical negligence litigation relating to childbirth from three to five years.
  • NHS England to provide funding to each NHS Trust to maintain a pool of appropriately trained interpreters with expertise in maternity, and to train NHS staff to work with interpreters.
  • Commit to tackling inequalities in maternity care among ethnic minorities, particularly Black and Asian women.
  • NIHR to commission research on the economic impact of birth trauma and injury, including factors such as women delaying returning to work.

Read about the birth trauma experiences of our clients Beata Bawolska and Zahra Iqbal, who submitted evidence to the Parliamentary Inquiry.

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Statutory Inquiry now needed as Birth Trauma report reveals ‘shockingly poor care’ across UK’s maternity services

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