Neonatal and Maternal Mortality Reports: September 2025

Background to the 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.

• Following a Care Quality Commission (CQC) inspection in April 2022, our maternity services were rated ‘inadequate’ and issued a warning notice. A follow-up inspection in March 2024 resulted in a further warning for Gloucestershire and a ‘requires improvement’ rating for Stroud Maternity Unit.
• Additionally, a BBC Panorama documentary that aired in January 2024 highlighted concerns about maternity care at our Trust between 2017 and 2021, including staffing challenges and the experiences of families and staff.

We have listened to our families and staff and this has helped us to make significant progress in improving our maternity services. However, to ensure we are doing everything possible to provide good quality, safe care for our families, we commissioned two independent reviews to identify any further learning and improvements.

The Reports

• Neonatal Mortality Review
• Maternal Death Review

If you would like to read these reports in another language, please contact our Pals team

Summary of Reviews

The two independent reviews were commissioned to identify what more we could learn from seven maternal deaths (2017–2023) and 44 neonatal deaths (2020–2023). These reviews were received in June and July 2025 and we have been meeting with the people and families involved through face-to-face meetings and ongoing support.

These reviews have highlighted some failings in the care we provided for a small number of families, and we offer our sincere apologies. We are fully committed to working closely with families and staff to listen, understand and ensure our services are safe and compassionate for every patient we care for.

We have undertaken a substantial programme of work to identify where improvements have already been made and where further action is needed. A robust plan is in place to address any outstanding areas for improvement. Alongside this, our priority remains engaging with the families involved in these reports to acknowledge our failings, hear their experiences and concerns and ensure they feel confident in the steps we are taking.

Key Improvements

While we recognise that there is more to do, we have made significant progress in maternity services, including recruitment of midwives and obstetric staff, improved governance, electronic access to maternity notes, and enhanced risk assessments. Specific improvements include:

• Increased staffing levels, including the equivalent of 25 additional midwives and 6 obstetricians to our service since April 2022
• New leadership structure and strengthened governance
• Improved induction process for agency staff
• Electronic access to maternity notes for women and families
• Following latest best practice for risk assessment and reducing major bleeding after birth
• Improving blood clot risk assessments
• Strengthening our internal Freedom to Speak Up service
• Providing a range of support for families and staff

The reviews have been shared with the people and families involved and their feedback has shaped our understanding and actions. We continue to listen and learn from every conversation; our staff have shared some powerful reflections from the conversations with the families involved and we recognise that each meeting brings new insights and helps us improve care.

We are co-designing future services with our Maternity and Neonatal Voices partnership (MNVP) and our local community. The Health Needs Assessment, led by the Integrated Care Board, includes engagement with women, birthing people, families, staff, and community partners. This ensures that future service development reflects the experiences of all and meets the needs of our local population.

The two reviews will be presented at our Board Meeting on 11 September 2025 as a Perinatal Mortality Review and published on our Maternity Improvement website. We remain committed to openness, accountability and continuous improvement.

We are already doing things differently and our new systems are making a difference, but there is more to do. We are committed to continuing to listen and involve service users, their families and staff in shaping our services.

Definitions

Maternal death: a maternal death is defined as the death of a woman during pregnancy and up to 42 days after the end of the pregnancy.

Neonatal death: a neonatal death is a baby born at any time during the pregnancy who lives, even briefly, but dies within four weeks (28 days) of being born.

• Please note that our neonatal review includes some cases beyond the formal definition of neonatal death. This broader scope was chosen to ensure that any potential learning was captured and reflected appropriately

Maternal Mortality Review

The independent external review looked at our safety incident management processes and identified any themes and learnings from the seven maternal deaths that occurred between 2017 and 2023.

The review made recommendations including improvements to the maternity clinical governance systems. Many of these have already been implemented.

Recommendations and progress

Venous Thromboembolism (VTE): blood clots prevention and treatment 

• Recommendation: Ensure appropriate and timely referral of high-risk women for appropriate treatment and monitoring, and that plans for future pregnancies are documented and shared with other care providers.
• Progress: Risk is assessed throughout pregnancy and postnatal care, with tailored preventative treatments recommended as needed. Compliance is monitored to ensure patient safety.

Major obstetric haemorrhage:  Managing a bleed after birth

• Recommendation: Follow the latest best practice to reduce major bleeding after birth, which has now been introduced.
• Progress: the latest national best-practice process is now used to reduce major bleeding after birth. It identifies at-risk women, enables consistent blood loss measurement, and supports faster response, helping to avoid transfusions and extended hospital stays.

Pregnancy care across the county 

• Recommendation: Ensure that any pregnant women with pre-existing medical conditions, or a social concern that might affect pregnancy can access timely and effective care and better sharing of information between care providers.
• Progress: Pregnant women with medical or social risk factors are supported through timely, tailored care and improved information sharing across providers to ensure safer outcomes.

Neonatal Mortality Review

The external review looked at any themes and learnings from the 44 neonatal deaths which occurred between 2020 and 2023.  Data from MBBRACE, the national team that investigates the deaths of women and babies who die during pregnancy or shortly after pregnancy in the UK, shows the Trust was below the England average during this period and in line with other maternity units with more than 4,000 births a year.

As well as a number of recommendations, the review found in nine of these deaths, there were missed opportunities in care that could have potentially changed the outcome for their baby.

Recommendations and progress

Enhancing Clinical Governance and Documentation

• Recommendation:  Implement an electronic patient record (EPR) across all maternity services
• Progress: There is a digital electronic patient record in maternity and this is being scoped for neonatal services.
• Recommendation:  Implement real-time audit dashboards for fetal monitoring, risk assessments and smoking cessation compliance.
• Progress: We have dashboards in place in these areas and compliance is monitored.
• Recommendation:  Mandate external oversight in Perinatal Mortality Reviews
• Progress: We have established external members who attend our reviews.

Optimising Antenatal Risk Assessment and Preterm Birth Pathways

• Recommendation: Establish a dedicated Preterm Birth Clinic, with clear referral criteria
• Progress: We have an established preterm birth service since 2022.
• Recommendation: Require a structured neonatal counselling for all women
• Progress: We have established processes for neonatal counselling.
• Recommendation: Develop a formalised in-utero transfer (IUT) decision-making protocol.
• Progress: We are piloting a new regional system and it is anticipated that this will improve our processes.

Strengthening Intrapartum and Neonatal Care Compliance

• Recommendation: Mandate annual multidisciplinary cardiotocograph (CTG) training and competency assessments
• Progress: We have mandated CTG training and have high levels of compliance with staff attending and this is based on the national competencies.
• Recommendation: Enhance decision-support tools for category 1&2 caesarean sections
• Progress: We are reviewing available tools to look at options for the service.
• Recommendation: Require fresh eyes reviews and real-time documentation in all intrapartum cases
• Progress: We have implemented hourly reviews and have good compliance with this being completed.
• Recommendation: Standardise neonatal resuscitation documentation with structured templates
• Progress:  We have standardised templates within our digital EPR and for our paper records.

Improving Postnatal safety netting for neonatal follow-up

• Recommendation: Develop a referral pathway for unwell neonates in the community
• Progress: We have a clear referral pathway and we strengthening awareness of this with our staff by carrying out education sessions.

Strengthening learning from mortality reviews and external benchmarking

• Recommendation: Ensure all Perinatal Mortality Tool (PMRT) action plans are time-bound, measurable and externally reviewed.
• Progress: We have strengthened our processes and will track them via our digital safety system (Datix). We have external presence at our Trust Safety and Experience Review Group (SERG) from the LMNS and the ICB.
• Recommendation: Implement benchmarking against national MBRRACE data to drive perinatal safety improvements
• Progress: We carry out regular benchmarking and have a Perinatal Transformation Programme.

Help and Support

If your question is not answered, or you would like more support, you can:

• Speak to your named midwife
• Contact our Patient Advice and Liaison Service (PALS) by phoning 0800 019 3282. This support line is available Monday to Friday from 8am until 3pm. If you call within these hours and need to leave a message you will receive a call back within one hour; if you call after this time, a member of the team will return your call by 9am the following day. Should you prefer to contact us by email to arrange a meeting, the PALS email address is: ghn-tr.pals.gloshospitals@nhs.net.
• Contact Gloucestershire Maternity and Neonatal Voices Partnership:
  www.glosmaternityvoices.nhs.uk
• Our web page outlines a wider range of support organisations