Mothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned.
More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said.
Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so.
Three major inquiries since 2015 have laid bare serious failures that have led to mothers and babies being harmed and even dying because of poor care provided by maternity services at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS hospital trusts.
A fourth, into maternity care at the Nottingham hospital trust and led by the midwifery expert Donna Ockenden – who investigated the Shrewsbury and Telford trust – is also under way. It is expected to report next year.
Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger.
His report says that: “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 services safer for everyone.”
Behrens said that the cases featured in his report were “extremely distressing”. They include Patricia Michael from London, who suffered bleeding in pregnancy in January 2020. Staff at the Barts Health trust in the capital did not perform an ultrasound scan to investigate why she was bleeding, which left her anxious.
They then did not explain to her how her baby could be delivered or that induction was an option. Michael also needed two operations when hospital staff removed her placenta manually, when it did not deliver naturally during the birth, but left a large part of it inside her. Their actions breached the trust’s maternity policy.
In addition, staff did not explain why her baby had a haematoma – a bruise caused by blood under the skin – on its head.
“What happened to me should never be allowed to happen to anyone else,” said Michael. “It was a traumatic experience that affected me deeply and still does.”
Behrens added that: “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 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.”
The Care Quality commission’s most recent annual report into maternity services in England said that the quality of care had deteriorated in recent years. It found that fewer mothers:
“Always” get the help they need at every stage of their care – before they give birth, during their labour, while they are still in hospital after giving birth and also in the weeks after they are discharged with their baby.
Were able to get advice about how to feed their baby during the evening, overnight and at weekends.
Feel that a concern they raise during their labour or birth is taken seriously.
