National Ombudsmen
Printable version

Repeated failings putting women and babies at risk

Too many women and babies are being put at risk as expectant and new parents are repeatedly ‘failed’ by maternity services, according to England’s Health Ombudsman.

In a new report, the Ombudsman warns that despite a number of major reviews into maternity services, lessons are not being learned.

The report shines a spotlight on these failings by sharing the stories of women who have been affected by failures in maternity services. It also provides advice about what anyone who finds themselves in a similar position can do to hold those responsible to account.

Through the stories in this report it is clear the same serious failings around communication, diagnosis, aftercare, and mental health support are still taking place, putting expectant and new mothers at risk. Significant changes need to be made to tackle these issues otherwise there will be more tragedies.

One story shared in the report was from Patricia Michael who experienced bleeding during her pregnancy. No ultrasound scans were carried out to investigate the bleeding.

Staff also 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 as it should. The placenta was removed manually rather than in an operating theatre under anaesthetic. This meant a large part of it remained. This caused Miss Michael a lot of pain and she needed two more operations to remove the rest of the placenta.

Staff also did not explain or provide Miss Michael with information about a haematoma on her baby’s head before she left the hospital. This caused her more distress.

Patricia, from London, yesterday 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 getting is the best and that everything is being done as it should be. 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.

We found failings in the way Miss O's pain relief was managed and poor communication from staff about what to expect from a miscarriage at this stage of pregnancy. We also found that staff had missed opportunities to check how her miscarriage was progressing.

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.

Parliamentary and Health Service Ombudsman Rob Behrens yesterday 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.”

Complainants have told PHSO during the course of its investigations that they want to make sure their stories are heard. They want what happened to them to matter.

This report aims to help others who may experience poor maternity care, to know what their options are and where to turn to for help.

It provides advice about how to complain to the NHS initially and, if someone is not satisfied with their response, how to escalate that to PHSO.

Mr Behrens yesterday 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.

“One of the main reasons people come to the Ombudsman is because they don’t want others to go through what happened to them. By sharing their experience, they can drive improvements to help stop mistakes happening again and make maternity services safer for everyone.”


Original article link:

Share this article

Latest News from
National Ombudsmen

Navigating WCAG 2.2 for UK Councils