1. Failures in maternity and neonatal care were ‘systemic, deep-rooted and sustained over many years’
At every stage of care received from the trust, from antenatal to postnatal, mothers and their babies were subject to deep-rooted and systemic issues. There were repeated failures to accurately report, grade and investigate serious occurrences, resulting in severe harm or even death to mothers and their babies, while such instances were routinely downgraded or dismissed as “unavoidable” to escape external scrutiny and protect the trust’s reputation.
A significant number of stillbirths, maternal deaths and severe complications could have been avoided if the care provided had been adequate, the report found. As regards the 462 stillbirths reviewed, about one in five of the case reviews of the mothers were graded 2 or 3, meaning significant or major concerns were identified in the patient’s care. Similarly, of the 27 maternal deaths reviewed, suboptimal care was identified in about a fifth (21.4%) of these cases.
The review also found a high number of mothers who received care from the trust experienced serious and severe complications. There were 142 cases of fourth-degree perineal tears, 130 unexpected admissions to the intensive care unit (ITU), 115 cases of massive obstetric haemorrhage and 76 cases of severe pre-eclampsia. Of the mothers who were admitted to intensive care, more than a third (35.6%) experienced care that was graded suboptimal.
2. Women and families were consistently ignored when their concerns were raised
Women consistently reported feeling dismissed, disempowered or blamed when they expressed anxiety or reported critical symptoms such as reduced foetal movements, severe pain, hypertension and postnatal deterioration. Instead of being taken seriously, their instincts and physical concerns were frequently minimised, normalised or reframed by staff as maternal anxiety. Families described how women felt they had to “prove” the legitimacy of their concerns before being seen or were actively discouraged from attending the hospital, which caused immense distress and eroded trust. One woman described being “sneered at for asking for pain relief”, while another was told, when she queried the medical care she received: “If you don’t like it, you should have gone somewhere else.”
A key example of women being ignored related to the case of baby Harriet Hawkins, who was stillborn. Despite her mother, Sarah Hawkins, making repeated phone calls to the hospital regarding intense, continuous pain and contractions, her symptoms were ignored and dismissed, and she was told repeatedly she was not in labour. Hawkins and her partner received £2.8m in a clinical negligence settlement from the trust, which is the largest payout ever for stillbirth clinical negligence.
3. Poor workplace culture and staff shortages
Chronic understaffing “was one of the most pervasive themes”, according to the report, with women repeatedly describing an environment where midwives and doctors were overstretched, exhausted and unable to respond promptly to requests for help.
A toxic culture of bullying among staff persisted over the decade, severely affecting staff wellbeing and patient safety. Within the report, staff described a normalised culture of hierarchy, nepotism and aggressive behaviour, in particular from labour ward coordinators. As a result, the report found, this toxic environment created a culture of fear where junior staff were too intimidated to escalate clinical concerns or challenge unsafe decisions.
Examples included labour ward coordinators who were observed writing terms such as “idiot” on the board when assigning midwives, instead of using their names. The review heard of incidents such as threatening letters being sent and urine being thrown over a staff member’s car, without any effective HR intervention.
This bullying culture was often used as a coping mechanism for the high-stress environment, according to the report, with one staff member stating: “In a harsh working environment you survive by becoming hard; the bullying culture is a way of managing your anxiety.”
Staffing shortages were chronic and affected all disciplines, including midwives, obstetricians and neonatal staff, with 80% of staff surveyed for the report stating there were not enough personnel for the workload and 59% regularly working beyond their rostered hours. Staff frequently had to manage several women in labour at the same time with no support. In the neonatal intensive care units, nurses reported being assigned up to nine babies at once.
4. Pre-existing health inequalities exacerbated poor care
The failures of staff to listen to women’s concerns during their maternity care was even more pronounced for women from Black, Asian and other ethnic backgrounds, as well as teenage mothers and those from more deprived backgrounds.
Mothers from minority backgrounds reported experiencing direct racism and a “toxic blame culture” where they were stereotyped and judged negatively if they were perceived as being “loud” or “too demanding”, while staff also noted that mothers from Traveller/Gypsy/Roma backgrounds were treated “particularly appallingly”.
In one case, a woman from a north African background reported persistent headaches, slurred speech and facial asymmetry, but hospital staff wrongly attributed her symptoms to “hormones” and ignored her family’s pleas for help; she later died from a brain tumour. In another case, a woman’s headaches, confusion and incontinence were inappropriately attributed to mental health concerns and a “language barrier”; she also later died from a brain tumour.
Other examples of marginalised women feeling stereotyped and dismissed included a doctor asking a woman from an ethnic minority background: “Why are you having another baby? You’ve had so many babies before”, which caused the mother significant distress and depression.
5. Psychological harm caused by poor care and failings in post-death care
The review uncovered severe systemic failings in mortuary and post-death care. This included the disposal of an early gestation baby as clinical waste, a deceased baby being kept in a domestic fridge instead of a mortuary, and placing a baby on a storage tray with an unrelated adult, which goes against guidelines. Families also repeatedly described a lack of compassionate bereavement care, poor communication regarding postmortem results and inappropriate mortuary environments.
The trauma caused by poor experiences for some mothers led them to end subsequent pregnancies. One mother, who had been “desperate to have any children”, discovered she was pregnant with her second child and said her immediate reaction was to seek a termination because she was “too frightened to go through the experience” again. Another mother told the review she had been diagnosed with post-traumatic stress disorder and said: “We haven’t had any more children, and that is why we haven’t had any more children, and I just don’t want to go through that again.”
