Women in England “failed” by maternity services, says report

Too many women and babies are being put at risk as expectant and new parents are “repeatedly failed” by maternity services, England’s health ombudsman has said.

In a new report, the Parliamentary and Health Service Ombudsman has warned 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 has found that repeated failings around communication, diagnosis, aftercare, and mental health support are still taking place, putting expectant and new mothers at risk.

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, the ombudsman has found

Staff also did not properly explain her delivery options or the induction of labour process.

After she had her baby, her placenta did not deliver naturally as it should. The placenta was removed manually, not in an operating theatre under anaesthetic, which meant a large part of it remained. This led to Patricia being in pain and needing two more operations to remove the rest of the placenta.

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

“What happened to me should never be allowed to happen to anyone else,” said Patricia.

“It was a traumatic experience that affected me deeply and still does. All women should be able to trust the care they’re receiving is the best and that everything is being done as it should be.

“You should not be made to feel wrong when raising your own concerns. You know your own body. 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.

PHSO found failings in the way her pain relief was managed, poor communication from staff about what to expect from a miscarriage at this stage of pregnancy and missed opportunities to check the progression of her miscarriage.

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, 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.

“Everyone has the right to complain if they receive poor care,” Behrens added.

“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.”