Neonatal and Maternal Mortality reviews: Frequently asked Questions (FAQs)

Why were these reviews commissioned?

There has been significant progress over the last few years to improve our maternity services, including recruitment and retention of midwives and additional obstetric staff.

Although we have made good progress, we felt it was essential to learn if there was anything more we could or should have been doing differently for mums and babies and we commissioned two independent objective reviews.

Is this an investigation of the neonatal unit?

The neonatal mortality review is a review of the maternity care received and is not a review of the neonatal unit at Gloucestershire Hospitals.

Are neonatal death rates higher in Gloucestershire?

All maternal deaths, neonatal deaths and stillbirths in England are included in MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) who produce a report every year.

The most recent data available is for 2023 and Gloucestershire’s figures can be found here: https://timms.le.ac.uk/mbrrace-uk-perinatal-mortality/data-viewer/ (select Gloucestershire from the drop-down menu).

Reducing the number of babies and mothers who die as a result of pregnancy and birth is a national priority, as well as a local one. As part of this work, there are national measurements for how many neonatal deaths occur in each maternity unit in England. This report tells us that the number of neonatal deaths in Gloucestershire is not higher than expected.

The external review looked at any themes and learnings from the 44 neonatal deaths which occurred between 2020 and 2023.  The MBBRACE data shows the Trust was well below the England average during this period and in line with other maternity units with more than 4,000 births a year.

What does “missed opportunities” mean?

When any maternal, neonatal death and stillbirth happens the care that was provided is reviewed to see if any part of care could have been different. As part of this review if we find any issues with care which might have had an impact the death the NHS calls this “missed opportunities”. This does not always mean the care caused the death, but it helps us identify where we might need to improve services.

Do you have enough midwives?

We have successfully recruited the equivalent of 25 new full-time midwives and 6 obstetricians to support families in Gloucestershire since April 2022.

We also work closely with local universities to train and support student midwives, many of whom choose to start their careers with us.

Are your services inclusive?

We aim to offer high-quality care to all families across Gloucestershire, regardless of background. We are committed to promoting equality and tackling discrimination. We regularly engage with community groups, including the MNVP, to make sure our services are accessible and supportive for everyone.

What actions have been taken since the reviews?

We’ve strengthened our maternity governance, improved clinical pathways for high-risk pregnancies, enhanced documentation and fetal monitoring, and introduced a dedicated preterm birth clinic.

We’ve also improved staff support, recruitment, and training, and are working closely with families to ensure they are heard and supported

How are families being supported?

We’ve met with families face-to-face, provided translated reports and lay summaries, and offered emotional and practical support. We are deeply sorry for the pain these families have endured and are committed to ensuring they receive the answers and care they deserve

What is being done to ensure the service improves?

We’ve implemented new systems to detect and respond to safety concerns earlier, improved our governance and escalation processes, and are embedding a culture of professional learning and openness. We are also working with NHS England and the ICB to ensure external oversight and support

Are your services safe?

We acknowledge that our services have not always met the standards families deserve. However, we are making significant improvements, and early evidence shows that these changes are making a difference. We are committed to delivering safe, compassionate care every day.

Help and support

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

1. Speak to your named midwife
2. 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.
3. Contact Gloucestershire Maternity and Neonatal Voices Partnership:
   www.glosmaternityvoices.nhs.uk