BBC Panorama has uncovered serious concerns about maternity services at Gloucestershire Hospitals NHS Trust, where midwives claim a poor culture and staff shortages have led to preventable baby deaths. The trust has apologized for its failings and pledged to learn from its mistakes. Two midwives are currently under investigation by the Nursing and Midwifery Council for their role in the deaths of two babies, Jasper White and Margot Bowtell, in 2019 and 2020 respectively.
The Gloucestershire trust is one of 10% of maternity units in England rated inadequate for safety by the Care Quality Commission. Current and former maternity staff at the trust have described the situation as “desperate” and claim that they repeatedly raised concerns about dangerous staff shortages with managers.
Between 2018 and 2022, seven women under the care of the Gloucestershire trust died while pregnant or shortly after giving birth, approximately twice the UK average for maternal deaths. In the first six months of 2023, the trust was short of more than 50 midwifery staff on average.
The mothers of Margot and Jasper have shared their experiences with the BBC, detailing the events leading up to their babies’ deaths and expressing their belief that quicker transfers to emergency facilities could have saved their children’s lives.
There are now calls for a national inquiry into maternity care failings across England. The Gloucestershire Hospitals NHS Trust has stated that it is “deeply sorry” for its failings and that independent investigations have led to “significant learning and changes”. However, Panorama’s investigation also revealed that the trust had a significantly higher maternal death rate than the UK average between 2018 and 2022.
In addition to these issues, Panorama found evidence of an incident in 2022 where a baby died due to insufficient staffing at the trust. The mother had been waiting five days to be induced due to a lack of available midwives. An investigation by the Healthcare Safety Investigation Branch concluded that “sufficient staffing may have altered the outcome for the baby”.