Gloucestershire maternity services under scrutiny: mortality reports reveal systemic failures

As highlighted, it has now been announced which 14 Trusts will be the focus of the newly launched National Maternity and Neonatal Investigation. Gloucestershire Hospitals NHS Foundation Trust is amongst them.

The news that Gloucestershire Hospitals NHS Foundation Trust was to be included, followed the Trust publishing two independent reviews looking into 44 neonatal deaths that occurred from 2020-2023, and seven maternal deaths that occurred from 2017-2023.

These reviews were commissioned in response to concerns about the quality of Maternity Care at the Trust and to identify areas for learning and improvement. 

The Care Quality Commission (CQC) rated the service “inadequate” in 2022, a follow-up inspection in 2024 resulted in a further warning and in a BBC Panorama documentary aired in January 2024 brought national attention to failings in care and governance within Maternity Services at the Trust. 

The Gloucestershire Hospitals NHS Foundation Trust Neonatal Mortality Review

The neonatal review examined 44 deaths and found that in nine cases, there could have been a different result due to “missed opportunities in care”. These included:

• Inadequate fetal monitoring, with gaps in CTG interpretation and escalation
• Delayed decision-making for emergency caesarean sections
• Incomplete documentation of neonatal resuscitation and stabilisation
• Failures in antenatal risk assessment, particularly around reduced fetal movements and safeguarding referrals

The review also raised concerns about the Trust’s internal investigations, noting a frequent lack of external input, underestimated assessments of care quality and weak action plans.

The Gloucestershire Hospitals NHS Foundation Trust Maternal Mortality Review

This report evaluated the Trust’s clinical governance response to the seven maternal deaths and considered emerging themes.

While the Trust’s maternal mortality rate was found to be statistically in line with the national average, the review identified several serious concerns:

• Four out of seven of the women died of Venous Thromboembolism (VTE) and cardiac disease, yet the Trust’s internal review failed to focus on these themes
• Major obstetric haemorrhage was poorly escalated in one case, despite actions plans being marked as complete
• A recurring issue was early pregnancy care, with five deaths occurring in the first or second trimester
• The report highlights poor coordination between primary and secondary care and limited assurance of pathway effectiveness
• There is incomplete implementation of actions from the Trust’s internal review, and the governance processes were described as “slow to react and cumbersome”

Improvements made, but more to do 

The Trust have emphasised that significant progress has been made in terms of their maternity services, including “recruitment of midwives and obstetric staff, improved governance, electronic access to maternity notes, and enhanced risk assessments”. However, the Trust has also acknowledged, that there is more to do and are committed to learning from these reviews.

The findings from the reviews point to a worrying history of systemic issues with care and governance at the Trust. For families affected, these reviews offer some acknowledgement of the challenges they have faced, but they cannot undo the lasting impact on their lives.

At Freeths, we understand the devastating impact that negligent maternity care can have on families. Our Clinical Negligence team has extensive experience supporting clients through complex claims involving birth injuries, maternal harm, and systemic failings in NHS trusts.