Maternity and Neonatal Scandals: Lessons Learned

26 Sep 2023 | Stephanie Prior
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Over the past 15 to 20 years, NHS maternity services have come under scrutiny as harmed families force accountability. Various investigations, reviews and court cases are the result. But will they make any difference to services? The lessons learned are perhaps not quite what you may expect.

Although Lucy Letby has been the most recent highly publicised criminal case against a trained clinical professional in a hospital setting, this follows multiple maternity scandals where similar questions have been asked as to lack of accountability and delays in addressing concerns.

Let’s remind ourselves of a few cases that came to national attention.

Mid and South Essex NHS Trust

The Mid and South Essex NHS Trust was formed from a merger of three Trusts, one of which was Basildon. In a 2020 assessment of Basildon maternity services, the Care Quality Commission (CQC) identified six incidents in which babies were starved of oxygen, resulting in the risk of brain damage. This shameful figure was in addition to the previously identified 27 stillbirths and 55 babies who were born with brain damage or cerebral palsy.

Nottingham University Hospitals

Covering the period between 2010 and 2020, an investigation into Nottingham’s maternal services found that at least 46 babies suffered brain damage, 19 were stillborn, and 15 mothers and babies died.

Shrewsbury and Telford hospitals

Senior midwife Donna Ockendon reviewed 20 years of maternity services provided by Shrewsbury and Telford hospitals. The results published in 2022 found at least 201 baby deaths, 94 brain injuries, and nine maternal deaths due to care failings.

Other hospitals that recently made headlines due to care concerns include the University Hospitals of Morecambe, East Kent; Queen Elizabeth The Queen Mother Hospital, Margate; Willam Harvey Hospital in Ashford; and the Countess of Chester Hospital, employer of the infant murderer, Lucy Letby.

Replicated dysfunction

According to the inquiries, within all the Trusts, there was a pervasive toxic culture which resulted in sub-standard clinical care. This toxic culture was fed by strained professional relationships, inadequate staffing and tone-deaf management.

For example, Basildon University Hospital’s maternity unit ‘did not always have enough staff to keep women safe ’, and the ‘dysfunctional’ working relationship between midwives and doctors contributed to safety breaches.

A former senior midwife described a ‘culture of fear’ in Nottingham University Hospital maternity units, in which managers ignored staffing concerns. The formal investigation into the Trust identified significant failures: failure to refer deaths to the coroner, failure of treatment and failure to recognise arising clinical complications.

Predictably, the 2022 report into East Kent maternity and neonatal services determined that, ‘critical care was suboptimal and led to significant harm’ while the Trust, ‘failed to listen to the families’ and acted in ways to compound their distress. An external assessor said the Trust exhibited, ‘the worst culture I’ve ever seen’.  The report identified:

  • gross failures of teamworking which, ‘hindered the ability to recognise developing problems’
  • lack of professionalism, lack of compassion, minimised problems and denial of responsibility
  • lack of action from Regulators and the Trust

Are recommendations optional?

Many investigations come with many recommendations for improvement. The East Kent inquiry found that overall, the NHS could be much better at identifying poorly performing unitsgiving care with compassion and kindnessteamwork and responding to challenges with honesty. The problem is, in the real world these aims are quite esoteric, and are difficult to measure in order to assess failure or improvement.

Then there is the Ockenden Report, which established four key pillars of improvement: safe staffing, a well-trained workforce, learning from incidents and listening to families. Again, it is hard to argue with these findings. These attributes should be integral to the NHS, but evidently are not.

Forced to reassure, forced to act

In light of reported service failings, it seems that some Trusts are taking notice. Facing publicised criticism, managers rush to reassure their catchment population that the services on which they rely are safe.

Following the recent downgrade by the CQC, the management of University Hospitals of Leicester maternity services released an open letter. In it, they state that many of the issues raised by the CQC were already being addressed.

The new measures include increased staffing, new equipment, daily safety checking, and improved infection prevention. However, rather than providing reassurance, this letter begs the question: why did it take a CQC downgrade to initiate necessary improvements?

What now for NHS maternity services?

For various reasons, time and money spent investigating negligent harm to mothers and babies is important. However, it seems that each new report is nothing more than a version of the previous one. This is because we already know the causes. We already know the solutions. What is missing is the impetus to effect meaningful change.

The foundational issue is this: dysfunctional maternity services are a symptom of more widespread problems within the NHS. While recommendations such as Ockendon’s key pillars may be worthy, they are practically meaningless without the government taking note, allocating funding and following through on meaningful plans of action.

Whistleblowers versus institutional reform

In the past, identification of dangerous clinical practice has fallen to whistleblowers. It is also frequently the case that a series of whistleblowers raise their head above the parapet and are shot down, before action is taken. In a recent example, the would-be whistleblower Dr Stephen Brearey was ignored when he and his colleagues raised concerns about Lucy Letby, and he now claims that more babies would have survived if hospital management had responded appropriately. Clearly whistleblowing is a tenuous route to improving standards and driving change: if action is not taken against potential baby murder, when will it be taken?

Lessons learned

So, in light of myriad investigation reports, the lessons to be learned are clear. As families continue to suffer, the inevitable investigations will continue to roll around. And until the NHS is permanently transformed, we will rely on internal and external whistleblowers to put the brakes on negligent and dangerous clinical practice, a concerning prospect indeed.

Stephanie Prior (Partner and Head of Clinical Negligence) recently spoke with Times Radio and LBC about the recent impact of Lucy Letby’s actions on the future for bringing potential civil claims.


Senior Associate Josie Robinson also recently spoke with Times Radio, regarding the same matter.


During their interviews, they advised that those who have been affected by negligence have the right to bring civil claims in negligence for compensation. Although it is recognised that no amount of money can make up for the loss of a loved one, civil claims also support families in seeking justice and a recognition of errors made by the medical professionals whose treatment was sub-standard, with the longer-term objective to devise ways to reduce the chances of such errors recurring, which may help save future lives.

When a child is injured due to medical negligence, they have until their 21st birthday to commence court proceedings. This means that even though the negligent treatment by the medical professional may have happened when the child was only a baby, there is still the option of bringing a claim for a significant period after the event in question. Therefore for parents or children alike, who maternity scandals and neonatal mistakes have impacted, our team at Osbornes Law would be more than happy to speak to you, if you wish to explore the matter of accountability.

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