Why is the UK mired in a maternity and neonatal deaths scandal? | Health News
Inquiries Reveal Substandard Care Linked to Rising Maternal and Neonatal Deaths in England
Two recent inquiries have identified inadequate care at multiple hospital trusts as a contributing factor to an increase in maternal and neonatal deaths in England. The reports spotlight serious failings in maternity services, particularly at Nottingham University Hospitals Trust.
The Ockenden report, which investigated maternity care in Nottingham, revealed that over 500 mothers and babies suffered harm or died as a result of poor care practices spanning 13 years. Led by midwife and childbirth expert Donna Ockenden, the report uncovered troubling accounts of “bullying” and cruel treatment within the Queen’s Medical Centre and Nottingham City Hospital.
The findings indicated that 444 women and 76 newborns experienced “potentially avoidable” health outcomes due to systemic shortcomings. The report noted that mothers in labor were frequently turned away from the maternity units, often when they should have been admitted. Both facilities faced chronic understaffing while failing to manage a complex volume of cases effectively.
In a parallel review, the Amos report, named in honor of Baroness Valerie Amos, echoed these findings, citing similar patterns of neglect across the British healthcare system. It criticized a culture that overlooked patient needs and highlighted instances of discrimination, with patients reporting biases based on race and background.
Amid these reports, the UK maternal mortality rate rose to 12.8 deaths per 100,000 maternities from 2022 to 2024, a rise of 20% compared to 2009-2011. Experts concluded that this trend indicated the government is falling short of its goal to halve maternal mortality.
Key areas of failure identified in the Ockenden report included insufficient listening to patients, lack of continuity of care, inadequate clinical governance, and prompt access to necessary imaging for women displaying concerning symptoms. The report also documented a culture where complaints were often met with attempts to cover up issues rather than address them.
In response to the findings, the Nottingham Maternity Families group, representing 600 affected families, called for the dismissal of senior managers who failed to cooperate with the inquiry. The group is advocating for a statutory public inquiry into maternity care across England.
Following the release of the report, Health Secretary James Murray described the Amos review as a “watershed moment.” He announced plans for structural changes to improve the culture surrounding maternity services, including the appointment of a maternity and neonatal commissioner accountable to Parliament.
Murray also committed an additional £41 million ($54.75 million) to enhance safety measures in maternity facilities, along with plans for creating 1,000 temporary midwifery positions and developing new national standards for emergency maternity care.
Research from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE) indicated that blood clots remain the leading cause of maternal death in the UK, followed by heart disease and mental health-related issues. The study also highlighted disparities, noting that Black women experienced a mortality rate nearly three times higher than that of their White counterparts.
Notably, similar investigations have surfaced in other regions, such as an independent inquiry in Leeds that revealed at least 56 preventable baby deaths and two maternal deaths between 2019 and 2024, prompting the Care Quality Commission to rate Leeds Teaching Hospitals as “inadequate.”
Experts continue to examine how systemic issues within the NHS and broader inequalities may be contributing to these rising rates of maternal and neonatal deaths, raising pressing questions about healthcare accessibility and quality across England.