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  2. News Article
    The care of women and babies at two Leeds hospitals presents a significant risk to their safety, the NHS regulator has said, after the preventable deaths of dozens of newborns. The Care Quality Commission (CQC) demanded urgent improvements to maternity services at Leeds general infirmary and St James’s hospital as it downgraded them to “inadequate”. A BBC investigation this year found that the deaths of at least 56 babies and two mothers may have been preventable at the two hospitals between January 2019 and July 2024. The hospitals, run by Leeds teaching hospitals NHS trust, are the latest to be engulfed by a maternity scandal that has revealed catastrophic failings in Nottingham, Shrewsbury and Telford, Morecambe Bay, east Kent and others. The downgrading of maternity and neonatal services in Leeds follows unannounced inspections by the CQC in December and January. Ann Ford, a director of operations at the CQC, said it had received concerns from staff, patients and families about safety and staffing levels at the two hospitals. She said: “During the inspection the concerns were substantiated, and this posed a significant risk to the safety of women, people using these services, and their babies as the staff shortages impacted on the timeliness of the care and support they received.” Inspectors found dirty areas on the maternity wards of both hospitals, unsafe storage of medicines, a “blame culture” that left staff unwilling to raise concerns, and short-staffed units. On the neonatal wards, which care for the most vulnerable newborns, the CQC found they were understaffed and infants needing special care were being transported unsafely from one hospital to another. Read full story Source: The Guardian, 20 June 2025
  3. News Article
    A police investigation into maternity services at two hospitals has started interviewing current and former members of staff. West Mercia Police began the inquiry in June 2020, while a review by senior midwife Donna Ockenden was ongoing - Ockenden would eventually find there had been catastrophic failings at the Shrewsbury and Telford Hospital Trust. The police investigation was set up to explore whether there was evidence to support a criminal case against the trust or any individuals involved. The hospital trust said it recognised it was important people get "the answers they have waited for" and that it was fully cooperating with police. The Ockenden inquiry examined maternity practices at Shrewsbury and Telford NHS Trust over a period of 20 years. Initially set up to examine 23 cases, it was widened to include almost 1,600 cases where there were concerns over maternity care. It found the failures may have led to the deaths of more than 200 babies, nine mothers and left other infants with life-changing injuries. Hundreds of the cases have been examined by police officers involved in Operation Lincoln. The senior officer in the police investigation, Supt Carl Moore, said the start of staff interviews represented a new phase. "We are committed to ensuring that the families involved are fully informed at each stage of our enquiries," he said. Read full story Source: BBC News, 19 June 2025
  4. News Article
    When Tassie Weaver went into labour at full term, she thought she was hours away from holding her first child. But by the time she was giving birth, she knew her son had died. Doctors had previously told Tassie to call her local maternity unit immediately, she says, as she was considered high risk and needed monitoring, due to high blood pressure and concerns about the baby's growth. But a midwife told her to stay at home. Three hours later she called again, worried because now she couldn't feel her baby moving. Again, she was told to stay at home, the same midwife saying that this was normal because women can be too distracted by their contractions to feel anything else. "I was treated as just a kind of hysterical woman in pain who doesn't know what's going on because it's their first pregnancy," the 39-year-old tells us. When she called a third time, a different midwife told her to come to hospital, but when she arrived it was too late. His heart had stopped beating. Tassie and her husband John believe Baxter's stillbirth at the Leeds General Infirmary (LGI), four years ago, could have been prevented - and a review by the trust identified care issues "likely to have made a difference to the outcome". The couple are among 47 new families who have contacted the BBC with concerns about inadequate maternity care at Leeds Teaching Hospitals (LTH) NHS Trust between 2017 and 2024. As well as the new families, three new whistleblowers - two who still work for the trust - have shared concerns about the standard of care at its two maternity units - at the LGI and St James' University Hospital. This is in addition to the two we spoke to in the initial BBC investigation. Read full story Source: BBC News, 17 June 2025
  5. News Article
    Dozens of trusts have been hit with financial penalties after regulators questioned their claims to be compliant with maternity safety standards. The maternity incentive scheme, run by NHS Resolution, gives trusts “refunds” on their payments to its clinical negligence scheme if they meet 10 safety-related criteria, which trust boards must declare against each year. The 10 requirements include appropriate staffing, reviewing deaths using a national tool, and board oversight of maternity services. However, NHS Resolution can investigate if concerns are raised — for example in a Care Quality Commission inspection — and these conflict with the trust’s submission. The payments to trusts can then be withdrawn, or withheld if they have not already been paid. HSJ analysis of data shared by NHS Resolution found 24 trusts had to make one or more repayments in the first four years of the scheme, which started in 2018 and was relaunched after the pandemic. Read full story (paywalled) Source: HSJ, 17 June 2025
  6. Content Article
    More information about "The Green Maternity Challenge: delivering safe, low carbon care"
    Angela Hayes, is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this blog, she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care: local screening for newborn developmental hip dysplasia supporting breast-feeding reducing health-inequalities for Albanian-speaking women. Background With births totalling over 673,000 in 2022, maternity services contribute significantly to the overall carbon footprint of the NHS, and therefore, to the environmental crisis. Pregnant women and infants are particularly vulnerable to climate change, which exacerbate existing health complications. Women from ethnic minorities or disadvantaged backgrounds are disproportionately affected so significant health inequalities persist. The Green Maternity Challenge was delivered in partnership with the Centre for Sustainable Healthcare, The Royal College of Obstetricians and Gynaecologists, The Royal College of Midwives and The Sustainable Healthcare. It aimed to: address the environmental impact of maternity care improve health outcomes create a more sustainable, equitable healthcare system. Nine clinical teams in the UK were chosen and supported by CSH to develop a Sustainable Quality Improvement project (SusQi) and measure its impact. Examples of impact Local screening for newborn developmental hip dysplasia - Orkney Due to geographical limitations, access to advanced equipment and specialist care and skills can be limited. Presently, families need to travel to Aberdeen with their newborns for the Ultrasound Newborn Screening for Hip Dysplasia. This has the potential to negatively affect clinical outcomes for patients, particularly those from peripheral areas such as Orkney Island, due to increased travel time and delay in travel owing to unpredictable weather, longer waiting periods and inconvenience to families. Local screening programmes can reduce waiting times and increase access to healthcare. It can also allow for early management and intervention in newborns. A team in Orkney introduced local screening facilities for newborn developmental hip dysplasia and eliminated the need for travel to the mainland. The programme has created increased job satisfaction for staff and reduced stress, travel and delays for patients. The environmental savings projected are around 22,500 miles and costs savings rising to £17000/year. Supporting breast-feeding - Great Western Hospitals NHS Foundation Trust Breastfeeding is important because it improves the long-term health of both mothers and babies. Between 74-86% of birthing people start breastfeeding in the first 48 hours. Around 8% stop breastfeeding by the time they go home from hospital and a further 20% stop during the first two weeks at home. There are several reasons for this, but a lack of infant feeding support is a major contributor. Lack of support also contributes to 5-20 mothers and babies a month requiring readmission for jaundice, weight loss and tongue tie. Staff on the post-natal ward at the Great Western Hospitals NHS Foundation Trust hoped to improve breast-feeding rates through the implementation of daily feeding support groups. They demonstrated improvements in effective person-centred care, staff satisfaction and patient confidence. With breast-feeding rates up by 5%, they projected yearly savings over £4600, reductions in re-admissions and outpatient appointments, and environmental savings equivalent to driving almost 5000 miles. Reducing health-inequalities for Albanian-speaking women - Kingston Vulnerable groups such as migrants and ethnic minorities, face various barriers in accessing healthcare, and as a result, face poorer clinical outcomes. One such example is that of Albanian speaking women in Kingston. Comprising of 1% of all maternity care bookings at Kingston (as compared to the 0.2% national population), Albanian women face various challenges such as language barriers, asylum seeking status, poor socio-economic status, lack of support, histories of human trafficking and sexual abuse, and pre-existing mental health conditions. They are also subject to discrimination and culturally insensitive care. All these factors contribute to underutilisation of healthcare services, limited access to high quality care, concerns about confidentiality as well as lack of faith in healthcare system. Delay in getting timely and appropriate care can lead to poorer health outcomes, often necessitating more intensive and resource heavy treatments. The Olive Clinic in Kingston & Richmond midwifery team arranged for an interpreter to support their ante-natal clinic for Albanian-speaking women to support them during and after pregnancy. Impact studies are yet to be measured but qualitative data shows encouraging results from women and midwives. Summary There are many more examples and case studies but these three particularly highlight how green initiatives can be aligned to patient safety improvements to make sure every newborn and every child receives safe care. With projected annual savings of £860,669, and carbon savings equivalent to 778,978 disposable nappies, they made a huge impact on sustainable and equitable maternity. Share your insights Do you have insights to share around balancing patient safety with sustainability? What are the challenges and opportunities? Contact the editorial team at [email protected] to share your ideas.
  7. News Article
    The trust with the highest perinatal mortality rates in the country has been told it must improve its midwifery staffing. Leeds Teaching Hospitals Trust is now reporting weekly to the Care Quality Commission about staffing on its maternity wards after being served a section 29A warning notice, it has emerged. It followed inspections of its maternity and neonatal services in December and January. The trust, one of the largest in England, has already moved some neonatal care out of one of its hospitals, after issues were raised by the inspection. It was also told to provide details to the CQC about how its board is informed about unmitigated risks and how its quality review meetings are assured over midwifery staffing, according to information seen by HSJ. The trust also promised to provide assurance shifts would be filled by qualified and competent staff and that its rota would be compliant with numbers dictated by the Birthrate Plus safer staffing tool. The requirements remain in force until the CQC decides they are no longer needed. Read full story (paywalled) Source: HSJ, 11 June 2025
  8. Content Article
    There is a well-established link between social determinants and poor maternal outcomes. National audits such as MBRRACE-UK, the National Maternity and Perinatal Audit (NMPA), and others have highlighted persistent inequalities in access, experience, and outcomes across maternity care in England. These findings underscore the importance of capturing the voices of those most affected by systemic disadvantage. Commissioned by NHS England and delivered by the Health Quality Improvement Partnership (HQIP) in 2024, this qualitative insight project set out to inform the development of an inclusive Patient-Reported Experience Measure (PREM) for maternity care. It focused on capturing the experiences of groups underrepresented in existing feedback mechanisms – particularly those facing socio-economic, cultural, or health-related disadvantage. The project combined a literature review, targeted outreach, and co-design with maternity charities to ensure engagement was inclusive and meaningful. The approach uncovered fresh insights, guided the prioritisation of participant groups and informed the design of engagement activities. Thematic analysis of participant insights and accompanying recommendations have supported the maternity PREM and contributed to broader efforts to reduce inequalities in maternity care. This case study outlines: The need for this work to deliberately reach those most affected by systemic disadvantage. The multi-stage, inclusive methodology used to capture diverse perspectives across the maternity care pathway. The impact the project had.
  9. News Article
    A computer file containing the details of cases linked to the NHS’s largest maternity scandal was “intentionally” and “maliciously” deleted, a police investigation has found. Nottinghamshire Police launched a probe earlier this year after records held by Nottinghamshire University Hospitals Foundation Trust (NUH) and linked to the alleged maternity failings were temporarily lost. The data was later recovered and 300 more cases are expected to be added to the inquiry into the scandal after a discrepancy was noted by a coroner. NUH is currently being investigated for potential corporate manslaughter after The Independent revealed babies had died or suffered serious injuries at its maternity units. The investigation into the deleted hospital data is not related to the corporate manslaughter probe. The trust is also the subject of an inquiry led by top midwife Donna Ockenden, who is investigating the cases of 2,400 families who experienced maternity care at the trust, including deaths and injuries. Read full story Source: The Independent, 10 June 2025
  10. Content Article
    In the US, women die at a greater rate in pregnancy and during the postpartum period than in any other high-income country, and this rate has been increasing. Even if some of the apparent increase is attributable to changes in reporting, the fact remains that in the US, mortality rates are rising rather than falling, while disparities are widening.1Yet despite recent efforts to prioritise women’s health research, pregnancy research remains woefully underfunded. Much of the existing funding for pregnancy research focuses not on the health of pregnant individuals themselves; rather, they are considered hosts whose social, intrinsic biological, and environmental determinants affect fetal and child development: an important perspective, but not the only one. A recent report by the National Academies of Sciences, Engineering, and Medicine noted that National Institutes of Health (NIH) spending on women’s health research in the past decade has averaged only 8.8% of its total budget, of which only a fraction went to study pregnancy. Despite progress in the form of new initiatives—such as the NIH Implementing a Maternal Health and Pregnancy Outcomes Vision for Everyone (IMPROVE) Initiative—funding for research regarding preconception, pregnant, and postpartum individuals remains a small proportion of the NIH portfolio.
  11. News Article
    A corporate manslaughter investigation has been opened into failings that led to hundreds of babies dying or being injured at maternity units in Nottingham. Nottinghamshire Police said it was examining whether maternity care provided by the Nottingham University Hospitals (NUH) NHS trust had been grossly negligent. The trust is at the centre of the largest maternity inquiry in the history of the NHS, with about 2,500 cases of neonatal deaths, stillbirths and harm to mothers and babies being examined by independent midwife Donna Ockenden. The police investigation will centre on two maternity units overseen by the trust, which runs the Queen's Medical Centre and Nottingham City Hospital. NUH said it was "deeply sorry for the pain and suffering caused", and it was "absolutely right" that accountability was taken. In a statement on the force's website, Det Supt Matthew Croome, from the investigation team, said corporate manslaughter was a "serious criminal offence". He said: "The offence relates to circumstances where an organisation has been grossly negligent in the management of its activities, which has then led to a person's death. "In such an investigation we are looking to see if the overall responsibility lies with the organisation rather than specific individuals and my investigation will look to ascertain if there is evidence that the Nottingham University Hospitals NHS Trust has committed this offence." The force said its investigation into deaths and serious injuries related to NUH's maternity care - called Operation Perth - had seen more than 200 family cases referred to it so far. Read full story Source: BBC News, 2 June 2025
  12. News Article
    At a UN-run antenatal clinic in a camp for people displaced by Boko Haram, the colours stand out like the bellies of the pregnant women. Abayas in neon green, dark brown and shades of yellow graze against the purple and white uniforms of nurses attending to them in the beige-orange halls of the maternal healthcare facility. Within the clinic in Maiduguri in north-east Nigeria, midwives and nurses are handing out free emergency home delivery kits, “dignity kits” for sexual abuse survivors and reusable sanitary pads to curb exploitation of young girls who cannot afford them. A dozen women sit on a mat in the corridor, awaiting the start of a session on reproductive health and doing their best to stay focused in the unwavering 42C heat. Among them is Yangana Mohammed, a smiling 32-year-old mother of seven who knits bama caps for a living. “I like that the services are free,” she said, holding a yellow medical card while waiting to change her birth control implant. “I’m really glad for this clinic.” Experts say more resources are needed to sustain these services in a region struggling with high maternal mortality, child marriage and female genital mutilation rates. UN global data for 2023, the most recent available, shows that Nigeria recorded 75,000 maternal deaths that year – nearly a third of the total worldwide. Many of those cases are among north-east Nigeria’s estimated 45 million people. Ritgak Tilley-Gyado, an Abuja-based senior health specialist at the World Bank, said disparities were fuelled by inequities in health systems and socioeconomic and sociocultural status across the country. “As a result, a woman in the north-east of the country is 10 times more likely to die from childbirth than her counterpart in the south-west … [with] a systems approach that tugs on the right levers, we can turn these abysmal numbers around and improve the wellbeing of mothers,” she said. Read full story Source: The Guardian, 21 May 2025
  13. News Article
    Two external reviews are being commissioned into maternity and neonatal care at the trust with the highest perinatal mortality rates. Leeds Teaching Hospitals Trust has claimed its extended perinatal mortality rate – which measures stillbirths and neonatal deaths – is within the expected range, considering it takes many high-risk pregnancies, including some where babies are not expected to survive, as a specialist centre. However, a report to its board meeting today reveals it is commissioning an external review of the issue. The review would examine mortality data. Read full article (Paywalled) Source: Health Service Journal, 29 May 2025
  14. News Article
    Wes Streeting has apologised to families harmed by poor maternity care for taking six months to get back to them, and claimed he is pressing NHS England for a “more comprehensive and stronger set of actions” to improve safety. The health and social care secretary had previously met with a group of campaigners for improved standards in December. But in a letter to them this week he admitted: “It has taken far longer than anticipated to come back to you with concrete plans for the actions we will take….I also realise that the lack of any update may have inadvertently implied that it was not a priority for me. This had never been my intention.” The letter, seen by HSJ, added: ”I was keen that they were sufficiently ambitious to reflect the scale of the challenge with maternity and neonatal care… I have asked NHS England to continue working up a more comprehensive and stronger set of actions that will deliver the change we need – and subject to your views would like to ask them to work directly with yourselves.” The delay in contact since December has caused some disquiet among families affected by recent maternity scandals, who felt they had been promised swifter action. Some groups favour a public inquiry into maternity nationally – which Mr Streeting is thought unlikely to offer – while other families hope for a “maternity czar” to drive forward change. In his letter this week, the MP said “on behalf of the Department, I offer my sincere apologies” for the delay in his response and action, and asked to meet the families again to discuss his plans, which include a set of immediate actions as well as longer-term plans to tackle entrenched issues. Read full story (paywalled) Source: HSJ, 28 May 2025
  15. Content Article
    Operational guidance to support health boards boards undertaking perinatal adverse event reviews incorporating the additional reporting required of maternity services. See also Maternity and neonatal (perinatal) adverse event review process for Scotland: Operational guidance to supplement the HIS national framework
  16. Content Article
    More information about "Evidencing the impact of culture on patient safety – a new tool from MNSI (a blog by Chris McQuitty)"
    In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI. This blog is part of our World Patient Safety Day 2025 series - Safe care for every newborn and every child. Why was COMPASS developed? COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹. The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers. Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety. What are the aims of COMPASS? We developed COMPASS for two key reasons: To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations. To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered. There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events. How is COMPASS being used? COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May. MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report. The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas. These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety. What is next for COMPASS? After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to: Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool. Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services. Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare. If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety. How can people find out more? Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety MNSI has launched a new patient safety tool COMPASS Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library References 1. The Patient Experience Library's Responding to Challenge report April 2025 Do you have a safety tool or project to share? Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at [email protected] to tell us more.
  17. News Article
    A delay in improving NHS maternity care is costing the lives of hundreds of babies a year, analysis has shown. At least 2,500 fewer babies would have died since 2018 if hospitals had managed to reduce the number of of stillbirths and neonatal and maternal deaths in England, as the government falls behind on its commitment to halve the rate of those three events. That is according to a joint report by the baby charities Tommy’s and Sands, which assesses NHS progress on meeting targets that were set in 2015. Dr Robert Wilson, head of the Sands and Tommy’s joint policy unit, said: “Hundreds of fewer babies a year would have died since 2018 if the government had met its ambition to halve the rates of stillbirths and neonatal deaths in England by 2025.” The 2,500 deaths are “the equivalent of around 100 primary school classrooms”, Wilson said. The stubbornly high rates of stillbirth and neonatal death, despite efforts to tackle them, showed that ministers were doing too little to reduce the incidence of baby loss, Wilson claimed. He said: “The response from government and policymakers to the ongoing crisis in maternity and neonatal care and the scale of pregnancy and baby loss in the UK is simply not good enough. Too many people continue to suffer the heartbreak of losing a baby.” Read full story Source: The Guardian, 20 May 2025
  18. Content Article
    Each year since May 2023 the Sands & Tommy’s Joint Policy Unit have published an annual report setting out the extent of pregnancy and baby deaths across the UK. This year’s report argues that progress made to date falls short of what is needed to stop babies dying every day in the UK, and that unacceptable inequalities in pregnancy and baby loss persist despite continued calls for change. It estimates that at least 2,500 fewer babies – the equivalent of around 100 primary school classrooms - would have died since 2018 if the government had achieved its ambition of halving the 2010 rates of stillbirth, neonatal and maternal deaths in England. The report draws on the latest data from MBRRACE-UK, which shows that the gap continues to grow between neonatal death rates in the most deprived areas and those in the least deprived areas of the UK. It highlights that the stillbirth rate among babies of Asian ethnicity has risen sharply, and Black babies are still twice as likely as White babies to be stillborn. It includes 10 key actions for policymakers Renew commitments to save babies’ lives. Specifically, a stillbirth rate of 2.0 stillbirths, and a neonatal mortality rate of 0.5 neonatal deaths for babies born at 24 weeks’ gestation and over (per 1,000 live births). A preterm birth rate of 6.0%. Count miscarriages in the UK. The number and rate of miscarriages are not reported across the UK or for any individual nation. All UK governments should set up routine data collection on miscarriage. Take coordinated and meaningful action to eliminate inequalities. There are a range of policy areas where specific action is needed, including: understanding whether current efforts to reduce inequalities are working, and a comprehensive review of translation and interpreting services in maternity and neonatal care. Strengthen national leadership to make progress on the safety of maternity and neonatal services. Clarify the workforce needed to deliver safe care. Future development of the workforce must move away from a binary debate focussed on whether we do or don’t have enough staff and focus on the staffing requirements needed to deliver safe care, in line with nationally-agreed standards. Put the resources needed in place to deliver safe care. More investment is needed to improve the safety and quality of services if the government is going to deliver on its commitments to reduce rates of stillbirth and neonatal death and eliminate inequalities. Make informed choice a reality. Everyone should receive personalised care, know what they are entitled to, such as their birth choices, and services need the resources and operational capacity to provide this. Address unwarranted variation in care. Too often babies are dying because of care that is not in line with nationally-agreed standards. We need clarity on how national guidance is applied and clear national standards to improve the consistency of service provision. Ensure lessons are learned when babies die. The NHS is still not properly learning lessons when babies die or listening to the experiences of bereaved families to improve care in the future. There must be more robust oversight of the implementation of actions that are identified by reviews and investigations. Prioritise pregnancy and baby loss in research. This requires a broad range of research topics, the involvement of bereaved parents and communities, and a strong connection with policy and practice.
  19. News Article
    Another major inquiry into patient safety within NHS maternity departments is being considered, HSJ has learned, this time by the Health Services Safety Investigations Body. HSJ has previously reported about concerns that trusts have been swamped with “overwhelming reporting requirements” and unclear regulation and standards on maternity as the result of a series of high profile reviews undertaken in recent years. HSSIB carries out thematic reviews of safety issues which do not apportion blame. It has not looked into maternity since it was launched in 2023. Chief executive Rosie Benneyworth told HSJ: “There are national issues in maternity… it was increasingly hard for us to explain why we were not looking at maternity as it appears to meet our criteria.” These criteria include systemic failings in multiple providers. Dr Benneyworth continued: “We are very keen that we don’t duplicate other work. The focus for us is making recommendations into national bodies. But we are very aware with maternity there has been an enormous amount of work.” The HSSIB investigation could examine why recommendations from other bodies and inquiries have not been implemented. It may also examine “risk management” and whether learning has been shared after incidents. It could lead to a series of reports published over a year. Read full story (paywalled) Source: HSJ, 20 May 2025
  20. News Article
    According to the Irish times, it comes after a series of serious incidents, including seven cases of babies suffering brain injuries during or after birth since 2024. A tenth review into maternity care at Portiuncula Hospital in Ballinasloe is now underway following the recent death of a baby. According to the Irish times, the HSE investigation, comes after a series of serious incidents, including seven cases of babies suffering brain injuries during or after birth since 2024. Six of those infants required specialist cooling treatment. Two stillbirths in 2023 are also under external review. Read full story Source: Shannon Side, 16 May 2025
  21. News Article
    NHS Tayside has been formally ordered to improve maternity services at Ninewells Hospital following an unannounced inspection by a health watchdog. Healthcare Improvement Scotland (HIS) expanded its safe delivery of care inspections following a neonatal mortality review last year to “provide women, birthing people and families with an assessment of the quality of care” in maternity services. It carried out its first safe delivery of care inspection in an unannounced visit to maternity services at Ninewells in Dundee between 27 and 29 January this year. This was followed up with another unannounced visit on February 12 due to concerns, including that breastfeeding equipment was being cleaned in a sink with kitchen utensils, which had not been addressed at the time of the return visit. In an inspection report published on Thursday, HIS said after the revisit, “we were not assured that sufficient progress or improvement had been made with some of our concerns”, and it formally wrote to NHS Tayside to urge it to meet national standards for maternity services. Concerns included “variations in oversight and governance observed in both the hospital inspection and maternity services, and a lack of oversight by senior managers within maternity services”. Other areas of improvement included “safe staffing, fire safety issues and the maintenance of the hospital environment”, according to HIS. Read full story Source: The Scotsman, 15 May 2025
  22. News Article
    A trust is set to close one of its birthing units for at least six months after admitting it “cannot safely run” the service. Somerset Foundation Trust will temporarily close the maternity unit at Yeovil District Hospital “for an initial period of six months” from next week, amid significant gaps in medical staffing. The trust has said it “cannot safely run” the special care baby unit, which provides dedicated support for premature newborns, nor “safely provide care during labour and birth”. The closure follows concerns being raised by the Care Quality Commission. The regulator rated maternity services at Yeovil “inadequate” last year and also issued a warning notice in January after finding its paediatric care “requires significant improvement”. The CQC said the service did not have enough medical staff or emergency equipment to keep babies safe, and found not all staff followed infection control procedures. Dr Iles added that senior paediatricians from Somerset FT’s Musgrove Park Hospital are helping to ensure paediatric inpatient and outpatient services at Yeovil remain open, including obstetric and midwifery antenatal clinics, scanning, antenatal screening services, and home births. But she added: “We cannot care for any newborns who require care in a special care baby unit or safely provide care during labour and birth at the Yeovil maternity unit. “We are committed to providing safe, high quality, and sustainable services for those who need them, but we must address these concerns and need the time and space to do this. I apologise again to anyone who is affected by these changes.” Read full story (paywalled) Source: HSJ, 15 May 2025
  23. News Article
    Two maternity units in Kent have shown signs of improvements three years after a damning independent review found up to 45 babies might have survived if they had received better care, a report has said. The Care Quality Commission (CQC) report rated maternity services at William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate as good, two years after they were downgraded to inadequate. The CQC said "significant improvements" had been made at both units to safety, leadership, culture, the environment and staffing levels. Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, said the report was "an important milestone in our continuing work to improve our services". Serena Coleman, CQC's deputy director of operations in Kent, said: "We found significant improvements and a better quality service for women, people using the service and their babies. "This turnaround in ratings across both services demonstrates what can be achieved with strong and capable leaders who focus on an inclusive and positive culture." Kaye Wilson, chief midwife for the South East at NHS England, said: "This report marks a turning point for services at East Kent and is the result of the commitment, determination and sheer hard work of midwives, obstetricians and the whole maternity team." Read full story Source: BBC News,15 May 2025
  24. News Article
    Two-thirds of specialist mental health services for mothers planned funding cuts last year despite soaring demand. An analysis of NHS spending by the Royal College of Psychiatrists (RCP) found 27 out of 42 areas in England planned cuts totalling £3.2 million in the 2024/25 financial year. Some areas such as Norfolk and Waveney planned to slash their budget by £257,466 - almost 5%. It comes as NHS figures show a surge in demand for people seeking help, with 63,858 women accessing perinatal mental health services in the year to February 2025, compared to 43,053 women in the year to February 2022. Baroness Luciana Berger, chair of the Maternal Mental Health Alliance, told The Independent it was "deeply alarmed" by the findings. "Our research shows that investing in perinatal mental health services is not only a compassionate choice but an economically sound one. Unaddressed perinatal mental illness takes a significant toll on families and costs the UK economy £8.1 billion a year. "Cuts to these vital services risk devastating human consequences. Mental health remains the leading cause of maternal death. These tragedies will persist without continued investment and protection for specialist services.” Read full story Source: The Independent, 8 May 2025 Further reading on the hub: Mums with babies in NICU: postnatal maternal mental health support Healthy beginnings, hopeful futures: Black maternal mental health
  25. News Article
    A leading midwife and chair of government maternity inquiries has cited “significant concern about safety and wellbeing” following a substantial cut to nationally ring-fenced funding. The concerns follow more than £90m of service development funding being cut from maternity allocations and transferred into core integrated care board budgets in 2025-26, as revealed by HSJ this week. NHS England said “maternity care remains a top priority” and it was “misleading” to suggest otherwise. But leading maternity safety campaigners and royal colleges expressed concerns that funding will now be lost because of deficits and competing demands. NHSE 2025-26 planning guidance says organisations must still “improve safety in maternity and neonatal services, delivering the key actions of the ‘three-year delivery plan’”, as well as “paying particular attention to challenged and fragile services, including maternity and neonatal”. Donna Ockenden, a former senior midwife, who chaired a government-commissioned review into maternity failings in Shropshire and is currently leading its inquiry into Nottingham Hospitals, said on social media site X: “Talking to colleagues across perinatal services, the sense of disappointment is profound, with everyone I’ve spoken to tonight expressing significant concern about safety and the wellbeing of children and mental health.” Influential safety campaigner James Titcombe said the move was “pulling in the opposite direction to promises health and social care secretary Wes Streeting had made to families failed by poor maternity care”. Read full story (paywalled) Source: HSJ, 1 May 2025

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