"'I’ve been trying to tell you something was wrong, I knew something was wrong.'"

A mother's experience of Oxford University Hospitals Maternity Services in 2018 and 2024:

My husband and I experienced serious and repeated failings in maternity care at the John Radcliffe Hospital, during the birth of our daughter in 2018 and our son in 2024. These experiences resulted in psychological trauma, physical complications, and unacceptable risks to the safety of both myself and my babies.

—————————————————————

First Birth – 2018

In 2018, I gave birth to my first child. I had hoped for a water birth at the local midwifery-led birth centre (with whom I’ve experienced nothing but the best care) but I was 2.5 weeks overdue and told this was no longer possible and that I needed to be induced at the JR. I had delayed the induction as long as I possibly could, and had multiple ‘stretch and sweeps’, in the hope of avoiding what I’d been warned (during NCT) could be a trajectory of medical interventions, likely resulting in a forceps or emergency caesarean delivery. 

We were the first induction on Sunday 30th September at 8.30am. Contractions started fairly soon, but I was told there were no delivery rooms available. It was advised that I walk around the grounds to keep things progressing, and to return and check in every couple of hours for monitoring. We did as we were advised, but by the evening the contractions disappointingly began to wane as there was still no room. I had become dehydrated (it was a hot day), exhausted and the baby was in distress. We were finally moved more than 12 hours later to Delivery Suite where things seemed to stabilise.

A midwife starting her shift came to examine me, and - without gaining consent - pulled out an implement and attempted to break my waters. It was one of the worst experiences of my life. After being unsuccessful she very aggressively told me I was “fighting her” and after multiple failed attempts, spanning about 40 mins, I was left hysterical. The head midwife - who was brought in to support - advised that we needed some time alone to calm down, before she returned and successfully broke my waters in a matter of seconds. She was so maternal, and scooped me into a cuddle and let me sob until I calmed - thank goodness for her. 

Unfortunately I failed to dilate further than 4cm, and was repeatedly instructed that I must agree to the hormonal drip. No pain relief was suggested and I recall having to fight for an epidural prior to the drip being started. In fact, a friend — and paramedic — who’d given birth the day before had yelled from the Level 5 window on our arrival at the JR the day before, “WHATEVER YOU DO, GET THE EPIDURAL!!!” which armed me with enough confidence to advocate hard. We were hours in and absolutely nothing was going anywhere close to the ‘plan’ - I was devastated, but thankfully the epidural was a welcome relief and felt like I was regaining a little control in a spiralling situation.

After a short while I began to shake uncontrollably, horribly nauseous, heaving, absolutely freezing, and progressively in unimaginable pain. When I told staff that something was wrong, I was ignored - they did not believe me. It went on so long that I developed a very real and frightening feeling that the baby and I were going to die and that no one was going to help us, and

I think my husband had similar fears, which was beyond awful to experience first hand, and observe in his eyes. 

After a long time a different anaesthetist finally came in to check on me, and very crossly (on my behalf) confirmed that the epidural had fallen out. I was cranked up to the max of the hormone drip, and rather than turning it down, I had to be held down by staff for them to start a new epidural. I felt like a crazed, caged animal, screaming, pinned to the bed. It was confirmed that I had developed sepsis, and as the baby was now in serious distress, an emergency caesarean section was our only option. I was beyond terrified, having never been in theatre before, but I have to admit for all the previous failings, the surgical team were incredible and I finally felt like we were being prioritised and maybe we’d be ok. 

Our daughter was born (some 40 hours after we arrived at the hospital) and, thankfully, all was well. In all the chaos and room changes, our bags were misplaced, and the staff were fairly put-out that the baby’s hat, vest, and blanket weren’t immediately accessible — my husband was made to feel awful at what should have been a joyful moment.

I hoped we’d been through the worst, but a few hours post op, I was separated from my husband, who had been firmly instructed to leave - against his wishes - as visiting hours were over. Around 1am, I was transferred alone - via wheelchair, barely dressed and somehow carrying my daughter in my arms - through the deserted hospital corridors by a male porter, and placed on Level 5, a boiling, dark, overcrowded postnatal ward where all I could hear were the cries of other mothers and babies.

There was no support available, despite recovering from major abdominal, emergency surgery and sepsis. I was unable to reach, or properly care, for my newborn without causing myself serious harm, but I worked tirelessly through the night to lift, comfort, support and (attempt to) feed her. I was not encouraged to use the buzzer to call for help (I don’t recall being shown that I even had one). Pain relief was not administered on time; paracetamol and ibuprofen (which bafflingly is all you’re prescribed) were missed, and the following day I required a dose of morphine to manage breakthrough pain as I was not coping. 

My antenatally harvested colostrum that I’d spent weeks expressing to bring to hospital - in case of an emergency situation such as this - had been lost by the staff, and I had to begin breastfeeding entirely unaided (which led to issues with my latch and weeks of agony with cracked and bleeding nipples) while connected to two very painful and awkwardly placed cannulas in both hands (one for fluids and one for antibiotics) and with unbelievable pain in the tummy / back. I felt I was left in unsafe and inhumane conditions, alone, without any medical support or compassionate care, and without my husband. The ward was unbearably hot (I spent the duration essentially naked) and noisy, and by the time I was discharged, I was so sleep deprived and overwhelmed that I had started to hallucinate. 

Despite having been at the JR for three days, the NIPE checks were not carried out and we were told, upon discharge, that we were booked at 9am the following day at the Horton Hospital. My milk had come in, we were awake all night, and had to battle through rush hour the next morning, only to find that the department name we were given didn’t exist, meaning we had to walk the full length of the hospital twice (just days after surgery) to locate the correct room.

When we arrived, a very unpleasant and angry Doctor shouted at us “are you the parents who were supposed to be here 45 minutes ago?!” before chastising us for being late, as if we were children. In the morning’s flurry we’d forgotten the red book - cue another scolding - and so my husband drove home to fetch it, leaving me alone with her. I was completely overwhelmed, in agony and exhausted, and her outburst tipped me over the edge and I broke down. She softened when I recounted the story of what we’d been through, but the damage had already been done.

The whole experience left me with an extreme fear surrounding birth - particularly vaginal examinations - and of returning to the JR. I was told during the consent authorisation pre surgery, that future births would be recommended to be via caesarean. This provided some comfort, but it took me six years to consider a second pregnancy.

Second Birth – 2024

My second pregnancy wasn’t entirely straight forward, and I was under consultant-led care due to the positioning of the placenta and a potential risk of ‘placenta accreta’ (where the placenta fuses to the scar tissue from a previous caesarean) and also a hematoma early on. I had been advised of the risks of VBAC (namely scar rupture) and that if I wanted to attempt a vaginal birth it would be on Delivery Suite with constant foetal heart monitoring. We were told a reasonable percentage of VBAC births resulted in emergency caesarean - something I was very keen to avoid happening again. 

Because of the trauma of my first birth, I requested a Birth Reflections session before attempting to get pregnant in 2023 — the representative was signed off on emergency leave, and so it was delayed until early 2024 when I was in early pregnancy. I was keen to try and understand what had gone wrong and to ensure this time would be different. My maternity notes had conveniently been lost, so we had nothing concrete to reference, but the representative I spoke to was kind, empathetic and apologetic. She admitted - shockingly - however, that Level 5 had sadly not improved since our last stay.

I tried to stay strong, and thankfully was supported throughout the pregnancy by the most incredible community midwife - who was determined to help turn things around and offer a compassionate and controlled experience. My history of birth trauma and the extreme distress caused by internal examinations were noted in my medical records and birth plan. I was clear throughout my antenatal care that I did not wish to attempt a vaginal birth - especially if it might result in an emergency caesarean anyway - and to my relief, a planned (elective) caesarean was clinically supported and approved, scheduled for 25th September 2024, at 39 weeks + 2 days. 

On Sunday 15th September, at 37+6, I began having what I thought was Braxton Hicks during a family party. After a few hours they developed into regular contractions, and it was clear I was in labour ahead of my c section date (the thing I was most fearful would happen). By the time I arrived at the MAU, I was clearly in active labour with strong, regular contractions (3 in 10) and in a lot of pain and distress. 

The environment on the MAU was chaotic and stressful. The waiting room was full of labouring women; the toilets were unclean, with blood splashes and specimen pots left uncollected. A woman was giving birth in one of the side rooms. I was terrified that I would ‘pass the point of no return’, and it would be too late to have a caesarean, and I’d end up birthing the baby, vaginally, in the MAU. I communicated this to the staff a number of times, and they seemed to understand. I had been briefed by my community midwife to be strong and clear on my wishes, and that I may ‘have a fight on my hands’ when arriving ‘early’ for an elective c section. 

Despite my symptoms and previous risk profile, I was not seen by a doctor. Instead, I was moved from room to room, and expected to lie still on a bed for monitoring - it was excruciating. Through tears I begrudgingly approved an internal examination (working so hard to control a panic attack), and was told my cervix was posterior and not to worry, no further examinations would be required (they had read my notes and understood the distress VE’s cause).

I was eventually transferred to Level 6, by which time I was in severe abdominal and back pain and now bleeding. Neither midwife on the floor introduced themselves or smiled to welcome us on arrival, they simply turned, stared, and looked back at their computer screens coldly. No pad had been recommended to monitor potential blood loss on arrival at the MAU, but a midwife crossly demanded I show her the blood when I mentioned I’d had some bleeding (which I couldn’t present). During our time there she made two inappropriate and hurtful comments that I will never forget - the first, a reminder that I was not the only woman she was looking after that evening. The second - when in total panic from the pain and fear of being ignored - that I was “fighting it” and “it could be a special experience” if I “calmed down”. This demonstrated a clear failure to read or follow my birth plan, which explicitly stated that a vaginal birth was not recommended nor my wish (and therefore would never be ‘special’), and dismissive of my pain and emotional fragility. In no way did she make any effort to help me calm down or create an environment that may support me to that end.

When the midwife requested medical review, the response given by the registrar downstairs was that I required a vaginal examination, had to be 4cm dilated, and that they had “nothing further to add to the conversation” until this had been carried out. I wasn’t able to agree to an examination by this time - not because I was being difficult or obstructive, as I was made to feel, but because I was contracting back to back and in pain beyond anything I’d ever known.

Despite worsening symptoms, I was again told that I could not have a caesarean until I was 4cm dilated. We now know this ‘policy’ was not evidence-based and directly contradicted both my risk profile and the pre-agreed care plan, taking no account of the trauma - that they had caused six years previous - of internal examinations.

My waters suddenly broke with significant bleeding. No one was there to help us and my husband had to clean the floor, as he feared I would slip and fall. The unpleasant midwife arrived, looked at the floor and the blood, went white, span on her heel and ran out of the room without a word. In a matter of seconds, I was rushed through the hospital in a wheelchair to theatre - wearing next to no clothes, with blood trailing behind me. I remember sobbing “I’ve been trying to tell you something was wrong, I knew something was wrong”. 

Before spinal anaesthesia was administered, I was asked emphatically to identify the ‘middle’ of my own back (as it was impossible to sit straight or still) despite being in no fit state to do so. I complied only because I had resigned myself to the fact that I was probably going to die anyway, so what did I have to lose? Once the epidural had taken effect, my first priority appeared to be to apologise to everyone in the room, fearing I’d been rude and needed to make amends. Looking back, this feels just tragic - it reveals how vulnerable and powerless I truly was, and how much of an inconvenience I had been made to feel previously. 

Upon examination, to my horror - and, strangely, a flicker of relief, mixed with an unexpected sense of pride - I was told I was 9cm dilated, confirming that I had been in active labour all along, just as I had been trying to convey. I was offered the choice of a vaginal birth or a caesarean - to my husband’s disbelief. I hesitated for a moment over the idea of a vaginal delivery; after all, I’d come so far, and it might mean avoiding the long post-op recovery. But in the end, I just wanted it all to be over, so I chose the caesarean. If I had opted for a vaginal birth, there’s no knowing whether we’d both still be alive: a placental abruption was confirmed during surgery. This was downplayed at the time as ‘the placenta had started to come away’, with the flippant comment that it was “lucky” I’d opted for the c section! I have since learnt that a placental abruption is a very serious, potentially life-threatening condition. I also now know I had all the textbook symptoms of an abruption, and it should have been spotted far sooner. The continued refusal to provide medical input was grossly negligent and could have cost me my life — and my baby’s.

In the recovery ward, after being united properly with my son (having had no time for any photographs upon his arrival due to the length / complexity of the surgery, which will forever hurt), a woman was placed in the bay opposite me, preparing for her planned caesarian. She was visited by the surgeon, midwives, and anaesthetist, who calmly and clearly explained what would happen and how she should prepare. I couldn’t believe what I was seeing - a level of care, communication, and respect so different from my own experience. It was the one I had been led to believe I would have. It was a stark reminder of how inconsistent and unpredictable maternity care can be, even within the same hospital, and how unaware the system / staff seemed to be of the care I should have received. It was also bewildering and distressing that a woman awaiting a planned procedure was placed right next to someone recovering from emergency surgery - an arrangement that felt both insensitive and poorly considered, for both parties.

One small mercy following discharge from the recovery ward was that I was transferred to a private side room on Level 5, as we had requested in advance - determined, after the poor care I received in 2018 - that my husband must be allowed to stay with me. This was granted, at least in part, because staff appeared to recognise the severity of what had occurred. The next morning, we were visited by a kind doctor who attempted to apologise for the experience, acknowledging that it should not have unfolded the way it did, and explaining - to our disbelief - that the ‘4cm dilation rule’ was not in fact hospital policy. While this might have been intended as reassurance, it only deepened the hurt, as it confirmed that everything we’d been through could and should have been avoided.

Postnatal Complications

Despite the traumatic delivery, I was not prescribed laxatives upon discharge, which led to an agonising, and totally undignified, bowel impaction once home - the results of which are not still completely resolved. For my pain relief to be administered ‘on time’ on the ward, I was advised to buzz the midwife, as they were short staffed and unlikely to get to me without prompting - this meant I was less able to rest, as I was managing my own pain relief. Staff also forgot to prescribe Fragmin, a very important blood thinner to help reduce the risk of DVT, and it was my husband who had to remind them before we left the ward (he administered the jabs himself in 2018 - if we were first time parents, we’d have had no idea of their need). 

I developed two extremely painful infections in the following weeks, with symptoms suggesting retained products of conception (placenta left behind during surgery). After multiple courses of antibiotics, my GP referred me for an urgent scan on 6th November, but the request was dismissed by the gynae team at the hospital on the grounds that I “seemed well,” (I suspect it was because I was ‘masking’, having applied makeup to try and feel more human) and the abdominal cramps I was experiencing were likely to be the return of menstruation - even though I was exclusively breastfeeding and only seven weeks postpartum.

I was placed on a long waiting list for the scan (9–12 weeks), so I arranged a private scan on 23rd December - another horribly traumatic, invasive experience - which identified possible retained products of conception (RPOC) or polyps. What the surgeon initially confirmed as RPOC was removed via hysteroscopy under general anaesthetic on 14th January 2025. To make the surgery possible, I had to leave my baby for 24 hours - when I simply wasn’t ready - and pump through the night to maintain milk supply. It was a huge and emotional undertaking. The histology report later suggested the biopsy was uterine fibroids. We have since learned there can be links between fibroids and placental abruptions, yet nothing had been detected during any of my antenatal scans. I wasn’t physically well until mid-February 2025, five months postpartum, and that was only because I was able to access private care through my workplace medical insurance. Had I waited for the JR, I would likely still be waiting and in chronic pain.

Both experiences demonstrate repeated and serious failings in the maternity care provided by the John Radcliffe Hospital. Failure to honour a pre-agreed and clinically recommended birth plan. Inappropriate use of outdated clinical thresholds (e.g., ‘4cm rule’). Refusal to escalate care or provide medical input in an active labour emergency. Dismissal of informed patient concerns and lived experience. Unsafe postnatal environments and inadequate staffing. Insufficient pain management and inadequate post-operative support. Delays in identifying and treating serious postnatal complications.

Both births involved avoidable risks to my health and the lives of my children. Despite every effort to advocate for safe care and avoid a repeat of 2018, I was placed in harm’s way again, and made to feel like I was the problem, rather than a mother in crisis simply asking to be heard and helped. I worry the trauma of the danger, pain and neglect of my son’s birth - all the more devastating because it was preventable - will haunt me forever.

My husband’s role throughout deserves acknowledgement. He tried so hard to advocate respectfully for me, asking questions and raising concerns, while balancing the impossible task of not being seen as confrontational - and therefore at risk of being dismissed or asked to leave, just when I needed him most. The emotional toll of this tightrope act was immense, as he too was frightened and powerless, desperate to keep us safe within a system that repeatedly failed to listen.

All this being said, we consider ourselves among the lucky ones - we have two healthy children, which at various points during both births felt far from guaranteed. The impact on my physical and mental health - and the knock on effect at home - however, has been huge. I am living with PTSD, marked by flashbacks, night terrors, and panic attacks. I’m ashamed to admit that I struggle to hear stories of people feeling well cared for at the JR, and even positive birth stories can sting. I hate that this is my response. 

My son is nine months old, and I am only now getting into my stride and able to enjoy the last few precious months of my maternity leave with him. The emotional weight of the experience, alongside navigating being a mummy to my daughter and a newborn, was overwhelming at times. I felt torn between the joy of motherhood and the shadows of trauma that I couldn’t seem to escape.

Devastatingly, the choice of whether we have any more children has been taken from us. We cannot face the risk of going through anything like this again. My trust in the John Radcliffe Hospital - and in the maternity care system as a whole - has been shattered. I am left with a persistent, irrational sense that I did something wrong, despite knowing deep down that I did everything I possibly could.