Mother miscarries alone on hospital floor as NHS makes ‘same mistakes’

Hospitals are making the “same mistakes over and over” when it comes to maternity care, the Health Ombudsman has warned, as it emerged a mother miscarried alone on a hospital floor.

Too many women and babies are being put at risk and repeatedly “failed” by the NHS, according to a new report, despite a number of major reviews in maternity services.

The study, based on complaints and compensation payments made to women for poor care, concluded that rapid changes must be made to England’s maternity services or more patients will come to harm.

Rob Behrens, Health Service Ombudsman, said that “if we do not start tackling these issues differently, there will be more tragedies”.

Miscarried onto floor of labour ward

One case detailed in the report is that of Miss O, who was 21 weeks’ pregnant when she miscarried her daughter alone onto the floor of a labour ward at Barts Health NHS Trust in 2020.

The Ombudsman found failings in her pain-relief management, poor communication from staff and missed opportunities to check the progression of her miscarriage.

After she left the hospital, the mortuary failed to tell the mother the date of her daughter’s funeral and she was buried without the family’s knowledge. The family was also subsequently given the wrong plot number for where she was interred.

The failings left Miss O experiencing pain longer than necessary, worsened an already traumatic experience, and made her anxious about going to hospital when she became pregnant again, the report found.

In another case, Patricia Michael was left in pain and required two further surgeries to remove part of the placenta following the birth of her baby. The placenta did not deliver naturally after birth, but manual removal by staff failed to remove it completely.

Miss Michael, from London, said: “What happened to me should never be allowed to happen to anyone else. 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.”

The new report comes following a series of high-profile reviews into individual maternity services across the country.

In 2015, the Morecambe Bay investigation found that serious failings led to the deaths of a mother and 11 babies.

Last year, Donna Ockenden’s report into the Shrewsbury and Telford Hospital NHS Trust, found systemic problems lead to the deaths of around 200 babies and nine mothers.

‘Callousness’ and ‘cruelty’

In October, an independent review into East Kent Hospitals University NHS Trust found up to 45 babies could have been saved after women were treated with “callousness” and “cruelty” by staff.

A further inquiry into maternity care at Nottingham University Hospitals NHS Trust is currently being carried out by midwifery expert Ms Ockenden, who led the review into Shrewsbury.

Mr 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.”

‘Decline in positive experiences’

The Ombudsman’s report pointed to the latest national NHS maternity survey, which “shows a decline in people’s positive experiences of using maternity services”, adding that “women are not being listened to when they raise concerns about their pregnancies, babies, or their own health”.

It added: “Many of the issues are well-known, and there has been a significant investment of time, energy and money to improve maternity care.

“We welcome the £127 million funding boost the Government announced on 24 March 2022 for maternity services across England.

“We also appreciate the hard work of healthcare staff to improve them, especially when the NHS is under such significant pressure.

“We recognise that people working in maternity services want to provide high-quality care.

“Culture, systems and processes can get in the way of achieving that goal.

“But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make maternity services safer for everyone.”