Maternity care failings ‘much worse’ than anticipated, says head of national review

Hungry mothers, dirty wards and poor care are blighting England’s maternity services while staff receive death threats for working in some units, according to a new report.

Baroness Amos, who is chairing a review into maternity care, said that what she has seen so far “has been much worse” than she’d anticipated.

Some women had felt blamed for their baby’s death, while others suffered from a lack of empathy, care or apology when things had gone wrong, with poor and black mothers often at the end of discriminatory services.

Health Secretary Wes Streeting, who set up the review, said “the systemic failures causing preventable tragedies cannot be ignored”.

Streeting said the update from Baroness Amos “demonstrates that too many families have been let down, with devastating consequences”.

“I know that NHS staff are dedicated professionals who want the best for mothers and babies, and that the vast majority of births are safe, but the systemic failures causing preventable tragedies cannot be ignored,” he said.

The National Maternity and Neonatal Investigation is meant to draw up a series of national recommendations to improve maternity and neonatal services after previous inquiries had exposed the problems but not led to enough sustained improvements.

The report from Baroness Amos – her reflections and initial impressions three months into the inquiry – highlight how ingrained poor care is.

Speaking to the BBC, the former UN diplomat said that she recognised there was “scepticism” and “criticism” of her approach.

“Time and time again, families feel that the system has failed them. I am very keen that that does not happen this time. And I think the fact that the Secretary of State has taken such a close interest is the thing that will make a big difference.”

Several inquiries over the past decade, including investigations into maternity services in Morecambe Bay, Shrewsbury & Telford and East Kent, have led to 748 recommendations for improvements being made, according to the Amos review.

Yet still the harm continues – the biggest maternity inquiry in the history of the NHS, examining around 2,500 case in Nottingham, is due to report in June while another inquiry was recently announced into care at Leeds Teaching Hospitals NHS trust.

Following visits to seven NHS trusts as well as meeting over 170 families, Baroness Amos said she had consistently come across:

• a lack of cleanliness, women not receiving meals, or getting help to use the bathroom with catheters not being emptied
• women not being listened to, including concerns about reduced fetal movements
• women of colour, working class women and those with mental health problems receiving discriminatory care
• NHS organisations “marking their own homework” when babies died or were harmed, with poor behaviours, including inappropriate language not being tackled

The review has also engaged with staff in maternity services. Some reported having rotten fruit thrown at them, while others said they faced death threats after negative publicity or were attacked on social media.

Adverse media attention could make delivering high quality care more difficult, they said, although it had also acted as catalyst for improvements.

Baroness Amos’s final report will be published in the Spring, but her inquiry is controversial. Some families believe that limitations on what it can do, and the short time is has to do it, will mean that meaningful action cannot follow.

The Maternity Safety Alliance, which wants to see a statutory public inquiry into maternity failings, said the initial reflections had “prioritised” staff feelings while minimising the “avoidable harm taking place in NHS maternity services every day”.

“This is entirely the wrong process to fix the deep seated and long standing failings in maternity care and we do not understand why [Wes Streeting] is allowing this farce to continue.”

Streeting will chair a new National Maternity and Neonatal Taskforce in the New Year which will be responsible for implementing Baroness Amos’s recommendations. He promised that families who’ve suffered poor care “will remain at the heart” of what follows the review.

James Titcombe, a long standing maternity safety campaigner since he lost his son Joshua in 2008, said that while the issues identified by Baroness Amos “mirror long-standing problems we’ve known about for years,” he was supportive of its work as representing “the best opportunity in a generation to finally put maternity services on a safer path.”