Capacity issues, depleted services, poor inter-team relationships, racism and bullying were just some of the findings released by Baroness Amos in her Interim Report as part of the National Maternity and Neonatal Investigation, which  is examining 12 NHS Trusts and their maternity services.

Lack of compassion, lack of transparency, outdated facilities and a shortage of staff were also listed by the Baroness in her initial findings.  

These interim findings, though deeply concerning, come as no surprise to me or to my colleagues in Switalskis’ Medical Negligence team. We have handled far too many cases of baby loss, child brain injury and injury to women and birthing people - as well as the traumatic impact on fathers and birthing partners - to be surprised by what the report sets out.

Damning but not surprising

Baroness Amos’ findings are incredibly worrying., Sadly however, they reflect what we see and hear all too often – that standards of care are simply not good enough in too many hospitals.

Her report mirrors what bereaved parents, injured women and birthing people have told us for years. It mirrors reports from historic investigations undertaken by Donna Ockenden and Dr Bill Kirkup, to name a few. Families are being failed every day, not by isolated mistakes but by systemic issues. we continue to see repeated reports of staff shortages, capacity issues, poor communication and working relationships, racism and discrimination, outdated facilities. The list goes on but most concerningly none of this is new.

We appear to be in a realm where the issues seem to be getting worse and not better. We are seeing more cases relating to maternity care from across the nation more regularly and we know that things have to change

This cannot simply be put down to resourcing challenges, significant though these certainly are. On many occasions poor management, deficient communication between teams or even broken professional relationships within teams are putting the lives of women, birthing people and their babies at risk, with catastrophic consequences for so many. How many more families have to suffer before effective action is taken?

Effective action long overdue – time for the government to act

We welcome the Health Secretary’s pledge to act on the findings, but words are not enough. We have heard for too long from other governments and other ministers that change will happen and yet we continue to face the challenges we see over and over again. It goes without saying, action has been needed for some time and, while we await an effective action plan and the improvements needed, more families, women ,birthing people  and babies will continue to suffer avoidable harm.

The government has much to consider. Baroness Amos’ findings focussed on six key areas, including:

• Services stopped or depleted because of capacity pressures; antenatal wards and delivery units stretched to the limit, resulting in delays to admissions and the use of community midwives in delivery units, all with an impact on safety
• "Poor relationships" between team members, including obstetricians and midwives, alongside a failure of senior management in not always dealing with racist and bullying behaviour by senior clinicians
• Structural racism and persistent inequalities, which has seen "notably higher risk of adverse outcomes" for women from black and Asian backgrounds and women from more deprived areas. This sits alongside discrimination against women who are disabled, Muslim families, refugee and asylum women and LGBT families.
• A lack of compassion and transparency when baby loss and injury occurs – often leading traumatised mothers wrongly to blame themselves, compounding their trauma and blocking opportunities to learn from mistakes
• Outdated and dilapidated buildings, in some cases compromising clinical care. Bereavement spaces were insufficient or even non-existent in some trusts
• Reports from staff that some maternity units did not have enough personnel to provide safe care.

Families deserve better

The consequences of failures in maternity care are absolutely devasting for families, with heart-breaking and life-changing events happening time and again, not just at some of the high-profile trusts where failure has become endemic but across the NHS.

Families deserve better and Baroness Amos’ final recommendations cannot come soon enough. What we have seen so far are only interim findings. Evidence is still being obtained before Baroness Amos’ final review and recommendations are concluded. We welcome the final report and her recommendations but in the meantime very much hope that this interim report will be an additional catalyst for change in many units.

Every single negligence case is an opportunity to improve care. This interim report is just an insight into some of the challenges that need to be addressed to ensure adequate and safe care are provided in all NHS maternity units. Until collaboration begins and effective change is made, women, birthing people, babies and families will continue to suffer. Actions speak louder than words and it is now time for urgent action to be taken to prevent further avoidable harm.