Publication of maternity reviews
In recent years, maternity care across the UK, including Gloucestershire, has been closely monitored and reviewed to ensure people receive the best possible care
While many families continue to have positive experiences, we know that some have not. We are listening carefully to their voices, and their experiences are guiding the changes we are making to ensure every family feels safe, supported and respected.
In 2024, we commissioned two independent reviews into maternal and neonatal deaths to identify any further learning and improvements. These independent reviews have confirmed some failings in the past and we recognise the devastating impact this has had on those affected.
We know some people will have had unanswered questions and we are doing our best to support them and help them to have the answers they need about the death of their loved one.
The two reviews will be presented as a Perinatal Mortality Review at our Board Meeting on 11 September 2025.
Read more details about the reviews
Kevin McNamara, Chief Executive of Gloucestershire Hospitals NHS Foundation Trust said:
“I am deeply sorry for any failings in our care and the devastating impact this has for those families affected.
“We commissioned two independent reviews into Neonatal deaths and Maternal deaths so that we could fully explore important questions about the quality of care between 2017-2023 and what else we need to focus on to ensure that every baby, every mother, and every family gets the best care possible.
"It’s really important to us that we are an organisation that is truly open and accountable. These reports look at care provided at the time and they offer a view of whether that care met the right standards expected. They highlight that for some babies who sadly died, there were gaps in care that may have contributed to their death.
"They also highlight that whilst most of those cases were investigated at that time, some were not. We got that wrong and for that I am truly sorry and we are now working with those families to do what we should have done at that time and fully investigate them.
"Over the past two years we have invested heavily in our maternity services and delivered improvements in care which include a significant increase in the number of Midwives and ongoing investment in doctors.
"But we know there is more to do and we continue to work with our regulators on many of the things identified as gaps at that time and we remain absolutely committed to continuing to build on that work and go further for the families of Gloucestershire."