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Racism and 'poor' staff relationships factors in maternity care failings, report finds

Michael Buchanan,Social affairs correspondentand

Adam Eley,BBC News

Getty Images Stock photo shows a pregnant woman lying on a hospital bed hooked up to care machines ahead of giving birth.Getty Images

The BBC has spent more than a decade speaking to families affected by poor care at NHS trusts across England (generic photo)

Maternity services in England are failing "too many" families, with problems "at every stage" of the maternity journey, an interim report has found.

Racism, staffing and accountability issues were among six factors identified by Baroness Amos, who is leading a government-commissioned review.

More than 8,000 people have so far submitted evidence, with Baroness Amos meeting more than 400 families.

Health Secretary Wes Streeting has promised to act on her final recommendations, which are due in April.

Baroness Amos told BBC Breakfast: "I have seen bad, poor, good and excellent care co-existing side by side.

"Families have described to me good experiences, terrible experiences. It is patchy, it is inconsistent and what this investigation is about, is trying to find out the things that move us from poor and bad to good and excellent.

"I am able to say categorically that there is safe care. There is good care, I have seen examples of it. But, I have also seen way too many examples of poor care.

"What I have heard from families it is so traumatic and distressing. I have seen Trusts that have changed their practices as a result of what has happened in those trusts. It is a very mixed picture. It is not consistent."

PA Health Secretary Wes Streeting in light blue shirt speaking to the media during a visit to the specialist surgical unit at Trafford General Hospital in ManchesterPA

Health Secretary Wes Streeting has promised to act on Baroness Amos's final recommendations, which are due in April

In her interim report, Baroness Amos centred her findings on six key areas. Issues found included:

  • Services depleted or stopped because of capacity pressures, with stretched antenatal wards and delivery units resulting in delays to admissions and the use of community midwives in delivery units impacting safety
  • "Poor relationships" between team members, including obstetricians and midwives. Racist and bullying behaviour of senior clinicians was not always dealt with by management
  • Structural racism and persistent inequalities leading to "notably higher risk of adverse outcomes" for women from black and Asian backgrounds and women from more deprived areas. Discrimination against disabled women, Muslim families, refugee and asylum women and LGBT families was also reported
  • A lack of compassion and transparency when baby loss and harm occurs, which can lead to mothers wrongly blaming themselves, compound trauma and impede opportunities to learn from mistakes
  • Care being delivered in outdated and dilapidated buildings, in some cases compromising clinical care. Bereavement spaces were insufficient or non-existent in some trusts
  • Staff reporting maternity units did not have enough personnel to provide safe care

Baroness Amos also said in a statement that it was "clear from the meetings and conversations I have had with hundreds of women, families and staff members across the country, that maternity and neonatal services in England are failing too many women, babies, families and staff".

Reuters Baroness Amos looks to the left of frame while wearing a grey and black striped top and necklace with bokeh background, as she walks outside while arriving for the Service of Thanksgiving for the Life and Work of Britain's former Foreign Secretary Robin Cook at St. Margaret's Church, Westminster Abbey, London December 5, 2005.Reuters

"Maternity and neonatal services in England are failing too many women, babies, families and staff," said Baroness Amos, who is leading a government-commissioned review (file photo)

Failures within the system have been known about, and reported on, for years. The BBC has spent more than a decade speaking to bereaved and harmed families following poor care at Morecambe Bay, Shrewsbury & Telford, East Kent, Nottingham, Leeds and a number of other NHS Trusts, gathering evidence of failing maternity services.

Orlando Davis died in September 2021, aged 14 days, after staff at Worthing Hospital in Sussex failed to spot his mother had developed hyponatremia, a lower than normal level of sodium in the bloodstream, during labour. An inquest concluded that neglect had contributed to the infant's death.

His mother, Robyn, said that "not listening to my concerns is the main reason we're sat here without our son".

Her husband Jonathan believes there is a "cultural" problem within maternity services that midwives believe they know better as they are the professionals. In actual fact, he said, "the only one that truly knows what's going on in that individual's body is the mother".

Family handout Newborn Orlando Davis, with his eyes open and a breathing tube attached to his nose with clear tape. He is wearing a white babygrow and his head is rested on what appears to be a white muslin clothFamily handout

Newborn Orlando Davis died aged just 14 days after hospital staff failed to spot his mother had developed hyponatremia

The couple are part of a group, Truth for Our Babies, who are campaigning for an independent investigation into maternity services at the University Hospitals Sussex NHS Trust. Earlier this month, BBC News and the New Statesman found that at least 55 babies over a five-year period might have survived with better care.

The Davis family does not believe that the Amos review will lead to better care across England and are calling for a statutory inquiry.

"It's not going deep enough... it's not just what's happening at these hospitals. It's the regulators as well," said Robyn. The regulators are not being reviewed by Baroness Amos.

"As families, we have received lacklustre care," added Jonathan. "We [therefore] deserve the gold standard of accountability - and progressing a rushed, high-level review, instead of a statutory inquiry, is not receiving the gold standard.

"Future mothers and future children may not suffer the same irreversible fate that we have if a [properly] conducted inquiry happens."

Jonathan and Robyn Davis sit next to one another, in front of a white wall, looking into the camera. Jonathan has short dark hair, and is wearing a dark blue and white patterned shirt. Robyn has long brown hair and is wearing a black and white patterned jumper

Jonathan and Robyn Davis said their concerns had not been listened to during labour

Labour MP Michelle Welsh, a prominent campaigner on maternity safety, says there is a danger the Amos review will become a damp squib and is urging the government to act decisively, including creating a maternity commissioner responsible for ensuring care improves.

"This inquiry must result in some big, bold policies with regards to maternity services, that really says that as a government we want to improve maternity services, we want to invest in it, and we will secure the truth and accountability for families," she said.

Announcing the review last June, Streeting also promised that he would chair a maternity taskforce early this year to drive improvements. But it's emerged this week that the group has not yet been established. The Department for Health and Social Care said they would be announcing the membership "shortly".

"It is important that the taskforce is established as soon as possible," said Welsh, "because without it we don't have that driving force [and] those big, bold policies."

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