Final Reports

Summary of the Individual Trust reports

The investigation spoke to women and families from across the country, each with their own personal and unique lived experiences. To enable us to work in a trauma informed way, separate sessions were held for families who had suffered harm and/or bereavement.

The reports are a reminder of the unacceptable care that some women, and families have experienced and continue to experience in some Trusts and may be deeply upsetting to families who are reminded of harm and loss.

We met staff working in different services and at different levels of seniority. In each Trust, we were told about staff burnout, stress and the immense pressures that staff were working under. Staff acknowledged that in these situations empathy and compassion could often be ‘the first thing to go.’

Across the 12 Trusts visited, there were consistent themes that emerged when reviewing the evidence. These are:

1) Women not being listened to:

Across all Trusts we heard from women and families who were not listened to, dismissed and excluded from decision making.

2) Staffing:

Staffing levels that do not match demand, leading to heavy workloads, and reduced continuity of care.

3) Demand and capacity:

High demand on services, alongside the increasingly complex care needs of women which puts pressure on available capacity. This leads to delays, overcrowding and, at times, care decisions being shaped by available space and patient flow rather than clinical need.

4) Leadership and governance:

Leadership and executive teams were aware of the challenges facing maternity and neonatal services but were not always equipped with the skills, knowledge and capabilities to make the changes required.

5) Response when things go wrong

Women and families across the country told us about traumatic experiences after things went wrong with slow or defensive responses from Trusts, apologies not/or grudgingly made which were felt to be meaningless.

6) Inequalities:

Inequalities across maternity and neonatal services were consistently raised during panel sessions with differences in experience linked to ethnicity, socioeconomic status, language, disability and gender.

7) Estates

Across the Trusts we saw examples of estates that were not fit for purpose. Women and families lacked privacy for sensitive conversations and staff were delivering care in cramped conditions

8) IT systems

Trusts are working with multiple IT systems that do not ‘talk to each other’ or are unable to share information. This can create potential patient safety risks if information is not consistently shared across platforms and creates additional burdens for staff.

What this means for Trusts

Structural and systemic issues mean that delivering kind and compassionate care is not always possible. We heard about teams operating with high levels of vacancies or working well beyond their hours because of the high demands on services. Staff told us about the scrutiny they were under, the fear of making mistakes given the media attention directed towards maternity services and the challenge of working in ’blame culture’.

We also heard positive experiences of teams working well together, supportive colleagues and initiatives that are leading to positive changes and outcomes for women, families and babies. 

Whilst meeting executive teams and senior leaders we saw different levels of understanding and engagement with what was happening in maternity and neonatal services in their Trust. We also saw, in the evidence that Trusts shared with us, differences in the governance systems for maternity and neonatal services. Some Trusts did not have a direct ‘ward to board’ governance mechanism with a resultant lack of executive oversight of what was happening on the ground.

At each Trust we also saw local improvements that were delivering results. However, there was limited evidence that these improvements or learnings were being shared across Trusts or that there was a mechanism that easily allowed Trusts to do so. This differs to other services such as Stroke or Cancer services where mechanisms or networks are in place that allow learning so that successful initiatives can easily be shared between Trusts.

Finally, it is important to consider when reading the Trust reports that often experience lags behind improvement. What this means is that Trusts may be on a learning journey and are putting in place improvement plans these improvements may not yet be consistently felt by women and families using the services.