Women and babies are at risk with the rise in the number of maternity care investigations, the Parliamentary and Health Service Ombudsman (PHSO) has warned today.
During 2023/24, the PHSO looked into 87% more maternity care cases than 2022/23 – up from 15 to 28. In the cases investigated, some of the issues identified included:
- delays to treating infection and performing MRI scans;
- failing to manage an epidural during a caesarean; and
- lack of consent for a procedure.
Things are far from improving
“The rise in maternity investigations and the number of complaints being upheld over the last four years give rise to real cause for concern,” said Rebecca Hilsenrath, the PHSO. She added: “It suggests that despite considerable investment in maternity care and well-publicised reviews into service failings, things are far from improving.
“There have been successive inquiries and reports into maternity care and no real evidence of change. We need to see lessons being learned. Our 2023 report found the safety and wellbeing of women is being put at risk due to the same mistakes being repeated.”
Some of the common themes highlighted in the report include poor communication as well as failings regarding diagnosis, aftercare, and mental health support.
The PHSO has carried out 80 detailed investigations pertaining to maternity care failings since April 2020. The NHS needs to take steps to share good practice and change what is going wrong, says Hilsenrath.
Patient’s concerns dismissed and not taken seriously
In a recently upheld case, 33-year-old Carly Hardwidge told clinicians seven times she could not feel her baby moving and that she was experiencing pain, contractions, water leakage, and had blood-stained discharge.
The PHSO concluded that staff at Royal United Hospitals Bath NHS Foundation Trust failed to act accordingly and properly investigate Carly’s concerns or refer her to an obstetrician. The PHSO says that – having had two miscarriages and pre-eclampsia – Carly should have been marked as high risk and placed under consultant care.
She should have also been referred to a senior consultant in September 2018 when she reported fluid loss for a third time – a similar referral could have been made when she reported lack of movement for a second time in November.
The PHSO adds that these failings led to Carly’s daughter being stillborn in December 2018. Hilsenrath continued: “The catalogue of failings by the Trust in this case is truly shocking and it led to the devastating loss of a baby.
“Once again, we see a patient’s concerns dismissed and not taken seriously. The lack of continuity of care meant nobody took a holistic view of what was happening. Ultimately, this led to the tragic avoidable death of a baby girl.”
A spokesperson for Royal United Hospitals Bath said: “We are deeply sorry for the tragic loss and emotional distress experienced by the family. We apologise for the failings identified and fully accept the recommendations of the Parliamentary Health Service Ombudsman.
“We all strive to provide excellent and safe care for women, birthing people and their babies and when harm happens, we spend time reflecting on and learning from what we could have done differently.
“We have made changes in response to this case, including training in relation to carrying out risk assessments and identifying when to refer to consultants and embedding a communication and escalation tool kit.”
The PHSO recommended the trust acknowledge its findings, apologise and set out relevant next steps to prevent the same things happening again. It was also told to pay £1k to recognise the impact of their failings in bereavement care and complaint handling. The failings in antenatal care have been referred to NHS Resolution.
Image credit: iStock
