"I had lost my daughter, endured multiple pregnancy losses, and had been physically and psychologically harmed by the care I received"

A mother’s experience of Oxford University Hospitals Maternity Services in 2020/21:

I am writing to step forward and join the families affected by maternity care at John Radcliffe. I am sharing my full account now because I have only just become aware of the scale of the current investigation, and because I finally feel able to speak after holding this for five years.

Our daughter, [daughter’s name], was stillborn on [date] 2021 at 39 weeks. She weighed 9lb 5oz. Before this pregnancy, I had already lost five pregnancies. Because of this history, I was vigilant and high alert throughout my pregnancy and reported every concerning symptom to my midwife.

From 32 weeks:

• I was measuring five weeks ahead

• I had rapid and extreme weight gain (over four stone on a nine-stone frame)

• I had significant oedema

• A urine test showed protein

• I was given a random (non-fasting) blood test, but no full investigation for gestational diabetes

Despite these symptoms, my due date was not reviewed and no discussion took place about early delivery or caesarean section. I went into labour at 39 weeks. I called the hospital and my call was returned an hour later. My waters had broken and were brown. It was around 11pm when we drove to the hospital, rushing through every red light.

On arrival, I was left in reception for approximately 20 minutes. I had to state twice that my waters were brown. When I was finally assessed, three different machines were tried before staff confirmed there was no heartbeat. I was wheeled between 3 rooms in the hospital and left alone for long periods in-between without updates or support with just gas and air in the final room. I begged and begged for pain relief.

After 5hrs I was eventually given an epidural and was left to sleep. The following morning, a midwife came in and realised that my daughter was completely stuck in my pelvis. I was taken to theatre and my husband was invited in. There were eight people in the room, with four taking turns to physically try to pull my daughter out of me.

After what felt like a very lengthy tug of war, my heart monitor was switched off and I heard my husband say, “I’m just going to move back.” I did not realise he was still there, and in that moment I thought I was about to die. I said, “It’s okay darling, you can go, I will be okay,” because I did not want him to witness losing us both that day. [Daughter’s name] was delivered weighing 9lb 5oz.

I was left with significant physical injury and no meaningful aftercare. I had a catheter and my stitches became infected. When the catheter later blocked, I returned to the hospital. I was treated as a major inconvenience by staff. The catheter was tied to the bed and painfully manipulated. I was told someone would return in 20 minutes. No one did. After an hour, during which we could hear staff laughing nearby, my husband asked if we could take me home.

The following night, the catheter blocked again. I was barely able to walk, standing in my bathroom, incontinent, in pain, and sobbing. When my infected stitches were checked I was sent to a ward for newborns, a wall of baby photos and the sound of newborns crying. I crumbled in a corner.

My bowel function never returned to normal and this was repeatedly dismissed as temporary. Two years later, after moving to Hampshire, I required surgery to repair a bowel prolapse. I still struggle.

After [daughter’s name]’s death, I participated fully in an HSIB investigation for nine months. I provided a detailed, chronological account of my pregnancy, every symptom I raised, and every interaction with the hospital. Throughout this process, I experienced what I can only describe as gaslighting. The final report included wording such as “mother did not understand educational signposting’, despite the depth and clarity of the information I had provided.

It became clear to me that the purpose of the investigation was not learning or protecting others, but managing risk and getting ahead of potential legal action. Mothers were asked to disclose every traumatic detail at their most vulnerable, only for their experiences to later be minimised or denied.

After months of advising them details were incorrect- I read the final report, I formally stated that I did not agree with the accuracy of its contents and that I no longer trusted the purpose of the investigation and wanted that formally logged against the report. I heard no more. At that point, I was 43. I had lost my daughter, endured multiple pregnancy losses, and had been physically and psychologically harmed by the care I received and the process that followed. I stepped away because I had to protect my sanity. I could not keep shouting into the wind while grieving my babies and the loss of motherhood itself.

We sold our house and moved as far away as we could from the healthcare trust, to the sea, to try to mend and heal.

After moving to Hampshire, clinicians at a different hospital trust reviewed my notes and told me that, based on my symptoms and [daughter’s name]’s birth, any future pregnancies would be treated as high risk for gestational diabetes and pre-eclampsia and I would be offered a caesarean section from 36 weeks.

Sadly, two subsequent pregnancies ended before seven weeks. I never got to become a mother. [Daughter’s name] was our miracle baby. I was invited to be part of an investigation so that lessons could be learnt. I believed them! That opportunity to protect other women, was taken from me.

I rediscovered the paperwork at the weekend and, through that, looked online to see whether I was alone or a one-off. Instead, I learned of the scale of the current maternity investigation and the number of families now coming forward.

Reading my own letters again made it clear just how badly my experience had been rewritten and minimised, and how necessary it was for me to add my voice. I am stepping forward now to stand alongside other families and to ensure that my daughter’s life, and what happened to us, is accurately recorded and cannot be dismissed.