26 Jan 2024, 9:13 a.m.

A BBC Panorama documentary on maternity will was broadcast on Monday 29 January 2024.

The documentary explored the challenges nationally in maternity, with a specific focus on our Trust’s maternity services. It includes the tragic deaths of two babies and a mother and interviews midwives and families.

Media statement

We are deeply sorry that failings in our care led to these tragic deaths and how devastating this has been for those families.

We are determined to learn and change when things go wrong. As a result of our internal and independent investigations we have made significant improvements to our maternity services in the past three years.

We have a new and expanded maternity leadership team and have increased the number of midwives and doctors into the service to support women and babies, alongside a range of other safety improvements, including an enhanced risk assessment process and extra daily staffing reviews on wards.

The significant changes made have been driven by our staff, working closely with families and communities, to ensure everyone has a voice so that we provide the best and safest care.

The Trust has published further information, including support for anyone affected by the documentary, on our website.

Figures used in the reporting


You can read the MBRRACE Statement here: How are maternal deaths calculated?

The national experts in maternal and neonatal deaths at Oxford University (MBRRACE) and the Local Maternity and Neonatal System, have independently reviewed the data for Gloucestershire and are clear that it is in line with the national average and is not statistically significantly different from the UK rate.

Improvements to Maternity Services

Our Maternity Services continue to go through a transformation process and as a Trust we are determined to learn and change when things go wrong.

These tragic cases panorama have reviewed took place between 2019 to 2021 and each one was independently investigated by an external body called the Healthcare Safety Investigation Branch - a body established specifically to offer an independent investigation when deaths occur in maternity.

As a result of those independent investigations and CQC inspections, we have already made significant improvements to our maternity services including:

  • New and expanded senior leadership team
  • We have increased the number of midwives and doctors into the service to support women and babies
  • Worked with staff to focus on patient safety, learning and continuous improvement
  • Introduced a new consultant midwife role, strengthening midwifery oversight of Midwifery led care
  • Ongoing recruiting and retention programme to reduce vacancies and turnover
  • Introduced a ‘Place of birth risk assessment’ to prevent delays in accessing urgent care if required
  • Three daily safety briefings to review staffing, workload and labour inductions - ensuring concerns are addressed immediately
  • Strengthened our internal Freedom to Speak Up service
  • Providing a range of support for staff, including wellbeing and psychological services, peer to peer networks, and safety champions.

Since April 2020 we have invested an additional £1.8 million to increase Maternity staffing, including obstetricians, consultants, administration support and the number of Midwives working in the department has increased from 242.99 (2020) to 263.77 (December 2023).