Bereaved families call for national inquiry into England’s maternity services

By Jane Kirby, Reporter31st October 2023News EnglandBereavment, Care Quality Commission, Care Standards, Hospitals, News England, NHS, Nursing / Midwifery

Families whose babies have died or been harmed at the hands of the NHS have come together to call for a full statutory inquiry into England’s maternity services.

The Maternity Safety Alliance, made up of bereaved families, has written to Health Secretary Steve Barclay asking for an England-wide investigation in the wake of repeated maternity scandals.

It comes after the Care Quality Commission (CQC) said 65% of maternity services are now regarded as inadequate or require improvement for safety.

Reports into failings at Morecambe Bay, Shrewsbury and Telford and East Kent have painted a damning picture of poor care and concerns over the culture on NHS maternity wards.

Donna Ockenden, who led the review at Shrewsbury and Telford, is currently leading an independent review of maternity services at the Nottingham University Hospitals NHS Trust.

Parents in Leicester have also called for an independent review into its maternity units following the deaths of their babies.

Now, the Maternity Safety Alliance has written to Mr Barclay setting out the case for a national inquiry.

It is signed by parents including Emily Barley, whose daughter Beatrice died in 2022 at Barnsley Hospital after staff mistakenly monitored her heart rate instead of the baby’s.

The letter is also signed by Jack and Sarah Hawkins, who were instrumental in bringing failings at Nottingham University Hospitals NHS Trust to light following the death of their daughter, Harriet; and national patient safety campaigner James Titcombe, whose son Joshua died at Morecambe Bay.

The letter said: “We are writing to you to demand a full statutory public inquiry into maternity safety in England.

“Our babies are too precious to keep on ignoring the reality that, despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies.

“Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed.

“Over and over again we hear that ‘lessons will be learned’ – and yet those same failings continue. And they don’t just continue in isolated corners of the NHS, they are present to some degree in almost every NHS trust in England, with the most serious kind of avoidable harm occurring everywhere.”

The families argue that only a judge-led, full statutory public inquiry can command the confidence of families and others involved, and come to independent conclusions “free of party politics”.

Ms Barley told the PA news agency: “We think the investigations and local level inquiries that have taken place are great and really useful…

“The problem for us is that the failings in maternity are much broader than these local units. They’re not isolated problems, it’s a system wide problem.

“We think we need a whole system analysis to really understand what’s going on and how it can be fixed.

“And we want that to include not just what’s happening in hospitals, but what’s happening around it as well, so at the regulators, in terms of governance, the way we learn from incidents – we think all of it needs to be looked at.

“The local investigations have been good but they haven’t fixed the problem…We’re seeing investigations years apart that are finding pretty much the same thing.”

She said the culture within the NHS was one of the biggest issues, including the focus in NHS trusts on “reputation management”.

She added there was “a kind of cultural acceptance of failure, an inevitability, even when it’s avoidable.”

Mr Titcombe said there must now be an acceptance that the problems are “not limited to isolated ‘unit level’ issues but rather reflect systemic problems that exist across the maternity system as a whole”.

He added: “Once we accept this as a starting point, it’s clear that future inquiries at an individual service level will only ever get us so far – no matter how many we have.”

Rhiannon Davies, Richard Stanton and Kayleigh and Colin Griffiths, whose daughters died due to failings at Shrewsbury and Telford, wrote to Mr Barclay in September calling for a national inquiry but Ms Davies told PA they have yet to receive a reply.

They have launched a petition calling for an inquiry on Change.org.

A Department of Health and Social Care spokeswoman said: “Every parent deserves to feel confident in the care they and their baby receive and we welcome the Care Quality Commission’s commitment to monitoring those trusts that are not providing an adequate standard, to ensure improvements are made.

“Nationally, we have invested £165 million a year since 2021 to grow the maternity workforce and improve neonatal services and we are promoting careers in midwifery by increasing training places by up to 3,650 over the past four years.

“The Care Quality Commission is also currently inspecting all NHS acute hospital maternity services that have not been inspected and rated since April 2021.”