Review finds nine infant deaths at trust ‘potentially avoidable’

A trust has apologised after an external review into maternity failures concluded that nine neonatal deaths may have been avoidable.

Gloucestershire Hospitals Foundation Trust announced in 2024 that its board had commissioned external reviews into deaths at its maternity services.

This followed an “inadequate” rating from the Care Quality Commission and a subsequent BBC Panorama investigation which raised concerns over cultural and staffing issues.

The reviews, which examined seven maternal deaths between 2017 and 2023 and 44 neonatal deaths between 2020 and 2023, found that nine of the neonatal deaths warranted further investigation due to “missed opportunities” in care that “could have potentially changed the outcome”.

Concerns included “incomplete risk assessments” during pregnancy, particularly around reduced foetal movements, and “misinterpreting” foetal heartbeat monitoring during labour and “delaying calling for senior review”.

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Source: HSJ, 8 September 2025