Women and babies are being repeatedly 'failed' by maternity services, with significant, immediate improvements needed to avoid more tragedies, according to England's Health Ombudsman.
In a damning new report, the Parliamentary and Health Service Ombudsman (PHSO) warns that, despite a number of major reviews recently carried out into maternity services in the UK (eg, the Morecambe Bay and East Kent investigations), lessons are not being learned.
The PHSO report outlines a number of "extremely distressing cases" of women who were affected by failures in maternity services. The findings highlight that serious failings around communication, diagnosis, aftercare, and mental health support are still taking place, putting expectant and new mothers at risk of poor care and avoidable tragic outcomes.
'Still Seeing Same Mistakes'
One story shared in the report was from Patricia Michael from London who experienced bleeding during her pregnancy. No ultrasound scans were carried out to investigate the bleeding, and staff did not properly explain her delivery options or the induction of labour process.
After Miss Michael had her baby, her placenta did not deliver naturally and was removed manually, not in an operating theatre under anaesthetic, which meant a large part of it remained. This led to her experiencing pain and needing two more operations to remove the rest of the placenta.
Staff also did not explain or provide Ms Michael with information about a haematoma on her baby's head before she left the hospital which caused her distress.
Miss Michael said: "What happened to me should never be allowed to happen to anyone else. It was a traumatic experience that affected me deeply and still does. All women should be able to trust the care they’re receiving is the best and that everything is being done as it should be.
"You should not be made to feel wrong when raising your own concerns. You know your own body. I hope that improvements are made so that no other woman has to go through what I did."
The report also shares the story of Miss O, who was 21 weeks pregnant when she miscarried her daughter alone onto the hospital floor while in a labour ward.
The PHSO found failings in the way her pain relief was managed, poor communication from staff about what to expect from a miscarriage at this stage of pregnancy, and missed opportunities to check the progression of her miscarriage.
After Miss O left the hospital, the mortuary service failed to tell her the date of her daughter's funeral, and the baby was buried without the family's knowledge. The family were then given the wrong plot number for where their daughter was buried.
'Extremely Distressing' Cases
Commenting on the report's findings, Parliamentary and Health Service Ombudsman Rob Behrens said: "These cases are extremely distressing. People should be able to trust that the care they receive during what should be one of the happiest times of their lives will be safe, effective, and compassionate.
"Sadly, this is often not the case. Failures in maternity care can have a devastating impact on women, their babies, and their families, and that impact can be long-lasting.
"Expectant and new parents are being failed right across the country, and very often in the same ways. The fact that we are still seeing the same mistakes over and over again shows that lessons are not being learned. This is unacceptable. There needs to be significant improvements and change."
During the investigations, complainants said that they want to make sure their stories were heard, and their experiences mattered.
Mr Behrens said: "Everyone has the right to complain if they receive poor care. I want to assure patients and families who have experienced something like this that their voice matters."
In response to the report, an NHS spokesperson said: "Providing safe and personalised maternity care to all women before, during and after their pregnancy is vitally important, and it is clear there have been severe failings in the care that women and families have received, when they should have been protected and cared for by our services.
"To ensure that we provide the best possible services for mothers, babies, and their families, we are investing £165m annually to grow our workforce, strengthen leadership, and improve culture, while continuing to work closely with NHS trusts and our partners to make necessary improvements."
Deterioration of Care in Surrey Maternity Service
Meanwhile, a maternity services inspection report published today by The Care Quality Commission (CQC) identified a serious deterioration in the quality and safety of maternity services in a Surrey hospital.
Investigators rated the maternity service at St Peter's Hospital, run by Ashford and St Peter's NHS Foundation Trust, as inadequate following an inspection in January. This was the first standalone inspection for the maternity service, which previously also included a gynaecology service.
Amy Jupp,CQCdeputy director of operations in the south of England, said: "It's concerning that the quality and safety of maternity care at St Peter's Hospital has deteriorated since our last inspection.
"Risk wasn't always well managed in the service. This included in the service's triage, where staff didn't always have enough time to appropriately assess and action risks faced by women or to maintain accurate care records.
Staffing difficulties were identified as some of the reasons causing the problems.
"While this is a problem affecting much of the NHS, leaders must find ways to ensure people's care isn't compromised by these staffing challenges," Ms Jupp said.
CQC served the trust a warning notice to take urgent action to ensure women and babies in its care are not exposed to risk of harm in the service. They will continue to monitor the service and the wider trust, as well as conduct future inspections.
This inspection was carried out as part of CQC’s national maternity services inspection programme.