The national maternity review erases our experiences

 

We feel betrayed by today’s publication of the final report of the National Maternity and Neonatal Investigation.

 

Our campaign group was formed in June 2024, and in just two years has grown to include almost 800 families harmed by OUH. 

 

We campaigned for the Trust to be included in the NMNI and were hopeful when it was announced that it would be.

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At face-to-face meetings with Baroness Amos and her team that we organised, our families shared painful experiences of baby loss, brain injuries at birth and devastating physical and psychological harm to women – and hundreds more responded in writing to the Investigation’s Call for Evidence.

 

Almost none of this is reflected in what has been published today.

 

We were promised a 'Families First' approach to the rapid review – a report that would put families at its heart. We believed this meant our voices would finally be heard, the toxic and dangerous culture we’ve experienced at OUH would be uncovered, and maternity services would become safer.

 

Despite the report’s central theme that women are not listened to, Amos has left us questioning whether she truly listened to us.

 

Harmed Oxfordshire families have waited years for an investigation like this. We held out so much hope and we deserved a report that reflected what we shared and the retraumatisation we experienced in sharing it.

 

Instead, the most painful and most common harms reported by families in our group have been erased.

 

Failure to address core themes of harm

 

Shockingly, the reports place a heavy emphasis on ‘estates’, which is mentioned 134 times across both publications. Yet any mention of brain injuries, bladder care and incontinence, forceps births and perineal tears is completely absent. The report also fails to cover psychological harm in depth, like postnatal depression, birth trauma and suicide.

 

A report meant to explain why mothers and babies are still being harmed devotes more attention to the condition of hospital buildings than to the bodily injuries and emotional trauma women continue to live with every day.

 

The trust-level report on OUH does engage more directly with some of what we have raised, including a finding that OUH’s OxGRIP scanning programme departs from NICE guidance, and a striking staff quote describing “the Oxford Way”: Woe betide you if you challenge it.”

 

We really welcome this honesty from staff but even there, double the page space is given to staff accounts of workload pressure than to families’ accounts of life-changing harm.

 

In highly emotional meetings with Baroness Amos, many parents were in tears as they shared their harrowing stories. This isn’t reflected in the report.

 

There is no mention of the women denied caesareans, denied pain relief, missed sepsis, or catheter neglect that families have shared with us, with OUH, and with regulators for years.

 

We are glad to see OUH’s latest CQC rating for its maternity services being brought into question in the report. A ‘requires improvement’ rating for safety reflects serious concerns about whether women and babies are consistently receiving safe care during childbirth. 

 

Against that context, and given the seven breaches identified in the ‘safe’ domain at the John Radcliffe, it is difficult to understand how the service can be rated ‘good’ overall.

 

Our families did not experience safe care during pregnancy, labour and the postnatal period, and we informed the CQC of this prior to the inspection.

 

Normal birth ideology

 

The Investigation’s own approach to analysing the evidence helps explain why this has happened. It says it used a “descriptive” method, which means it focused on recording what people explicitly said, rather than looking for underlying patterns in the evidence.

 

But some of the most important issues are not usually stated directly. For example, a culture that prioritises “normal birth” over safety is not something people will necessarily describe in those exact terms. It only becomes clear when you look across many different accounts and join the patterns together.

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A method that focuses mainly on clear, repeated and concrete complaints – such as staffing levels or hospital buildings – is much less likely to pick up issues that require interpretation and pattern recognition.

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We don’t believe this was simply an oversight.

 

Dr. Bill Kirkup CBE – who chaired the Morecambe Bay and East Kent maternity investigations, and is a respected patient safety expert – resigned from the Investigation’s own Expert Advisory panel just over a week before publication. The report itself records why: he could not agree the wording of its conclusions on “normal birth ideology.”

 

The Investigation’s most senior independent expert did not sign off on the conclusion it ultimately published. For us, that suggests that the idea that the Investigation did not find evidence of normal birth ideology in England’s maternity services is dubious at best.

 

Campaign members' responses

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Angel-Kay:

 

“The National Maternity and Neonatal Investigation was supposed to be conducted through a family centred approach. Yet, out of the 25 pages written about OUH, there are only 5 pages based on what families spoke about, and even they lack emotion. I found the recommendations about listening to families to be ironic. The quotes chosen and reflected about OUH in this report do not even come close to the stories that Baroness Amos and her team were told in the meetings. We stood up and we spoke about our most vulnerable moments and yet, it seems that none of them were truly willing to listen.”

 

Anonymous:

 

“Upon reading the report today, I felt angry that I attended the NMNI meeting just two months after losing my baby girl, hoping that someone would listen. Clearly, a report that states women aren't listened to has not listened to us either - this report makes me feel not listened to all over again."

 

Chloe*:

 

“As families, we have been failed time and time again - first by the midwives and obstetricians we trusted with our care, then by the trust leaders who dismissed our concerns. We placed our hope in this investigation, believing it would finally give families a voice and deliver the accountability we have fought so hard for. Instead, I feel deeply let down by the NMNI report.

 

We were promised a family-focused investigation, but the report does not fully reflect the devastating and lifelong impact that these failures have had on families. While estate issues are important, they should not over overshadow the deeper failures in care - the lifelong trauma, loss and families lives that have been changed forever. We deserved a report that truly recognised that harm.”

 

Laura:

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“The opening remarks from the Amos review demonstrate the gravity of the current situation of maternity services across the U.K., and that Amos herself, with her team, took on board the intense trauma and lifelong implications of the current maternity care offering in the trusts they visited.

 

However, this is where the sentiment ends. I am hugely disappointed in a “families first” approach that the depth of the situation is not told by families voices in this report, but bolstered by how the staff feel and experience the services that they provide everyday.

 

I am under no illusion that it is a difficult job, under stretched systems and service but, midwifery and obstetrics is a vocation, one which any member of staff may leave and resign from at any time. For families failed by the service, they do not have this privilege. They must live with the lifelong consequences of failures done to them by a system and service that is utterly abysmal.

 

In no other area of healthcare or medicine would we tolerate such little accountability or witness such appalling levels of care and allow it to continue. It continues to exacerbate women’s health inequalities and the gender health gap. Most of all I am maddened by the approach to solution for the state of maternity and that very real and probable solutions offered up by families have not formed part of this document.

 

I stand with every family that feels utterly betrayed and let down. I feel this is a huge missed opportunity to align real solutions to a broken system that could ultimately save lives.”

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Claire*:

 

“I am horrified and extremely disappointed by the Amos report. By attending a meeting, I felt it was an opportunity to finally be heard but reading the report I am doubting that we were listened to at all. The overriding comments about estates does not reflect the concerns of the meeting group I attended. There is no mention about tears, minimal mention about breastfeeding issues and brain damaged and dead babies. These were the issues that stood out to me when in the family meeting and the horrendous experiences and things OUH staff have said to families.

 

I completely agree with the staff about safe staffing levels, if you are that busy it doesn’t get filled in and then passes as ok! Way too much emphasis is given to staff about the media campaign which is happening for a reason! Pretty sure the hospital uses social media as effectively as it can trying to cancel out the horrific stories with older ‘good’ stories.

 

The comment about historical issues disgusts me – they are not historical! The comments about elective c sections disgust me. Staff may think they know best, but until you speak to that woman and hear her reasons, they have no idea. As professionals, it is our job to listen to our patients/ clients and I feel that maternity still operates very differently to this.”

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*pseudonyms to protect identities

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