Maternity Updates

We have proactively requested and welcomed reviews into our services - including from the Care Quality Commission (CQC) - which are now helping us to learn more quickly and make changes. A lot of work is underway already to help us get there. We will use this space to share publicly what we are doing and to provide updates on our progress.

1 July 2025

A statement in response to the National maternity announcement

On 23 June 2025, the Secretary of State for Health and Social Care, announced a national investigation into maternity care, and a maternity and neonatal taskforce to share learning and best practice will also be established.

The investigation will consist of two parts. The first will urgently investigate up to 10 of the most concerning maternity and neonatal units, to give affected families answers as quickly as possible.

The second will undertake a system-wide look at maternity and neonatal care, bringing together lessons from past inquiries to create one clear, national set of actions to improve care across every NHS maternity service.

The national review will pull together recommendations from inquiries to assess progress and to provide clarity on direction for the NHS.

You can read more about the announcement here: National maternity investigation launched to drive improvements

As a Trust, we are determined to learn and change when things go wrong and over the past four years, we have made improvements to our maternity services, but recognise there is more still to do.

Following Panorama in 2024 we asked ourselves a number of critical questions and commissioned two independent reviews into our neonatal and maternity services, which we plan to publish towards the end of the summer.

Extensive work has taken place in recent time to improve our services and the care we provide, and also to plan well for the future. This has included significant midwifery recruitment in particular and more safety measures.

A critical element is ensuring that improvements that we make are sustained and we know that more challenges remain and we need to be relentless in focusing on them, including governance, culture and staffing levels.

Health Needs Assessment

We are committed to listening, learning, and acting, ensuring that every voice is heard and the improvements we continue to make are driven by our staff and working closely with families and communities.

An important part of this work is the health needs assessment that is already underway with NHS Gloucestershire so that people can help shape the future development for our maternity service.

Once the national review and the local needs assessment process is complete, we will set out ideas on how services could be developed. We are keen that any proposals for future service development are co-designed through meaningful engagement.

We fully support the national review announced today and the establishment of the maternity and neonatal taskforce to share learning and best practice. We believe these developments have real potential to benefit our services in the county and those who use them.

Kevin McNamara, Chief Executive, Gloucestershire Hospitals NHS Foundation Trust said,

“I am truly sorry that for some women, babies and families in Gloucestershire, the standard of care has not been good enough. I know that has meant a poor experience for some and a devastating one for some others.

We continue to work on the improvements needed, which over the past year or so has included a significant increase in our Midwifery staffing. And these are having a positive impact today.

But there is more to do, and we will keep pushing for the changes that will get things right for every mum and baby.

The national review is an important announcement, not just for Gloucestershire but for the whole NHS. It is one we fully support so we can ensure every family receives safe, responsive, and compassionate care.”

15 May 2025

A statement in response to recent media coverage about stillbirths at Gloucestershire Hospitals

In response to the articles published in the media last week, we want to reach out to anyone who has been affected by this information. We recognise that the loss of a baby in pregnancy, during or after birth, has a lifelong impact. Our thoughts are with every person and family that has lived through this unexpected and painful experience.

The figures in the articles are from the Perinatal Quality Dashboard presented at our Trust Board meeting on 8 May, which is published publicly on our website: May 2025 Board Papers. This is a report we publish every three months as part of our work to ensure both real openness and learning across a huge range of different areas we monitor within our maternity services.

Stillbirths are devastating events for women, their partners and their families. The grief of losing a baby has a profound impact on those affected, with much support being required in the immediate aftermath and for many months following.

We take the loss of every baby seriously. Reviewing and monitoring stillbirths is a key part of our maternity quality work and our commitment to providing safe care for everyone.

There were nine stillbirths in Gloucestershire across September, October, November and December 2024.

When a baby is stillborn, we review the care that the mother, or birthing person, and the baby received. At the end of 2024, we saw an increase in the number of babies stillborn in Gloucestershire. Because of this, in addition to our normal reviews, we commissioned an external independent review of the care that had been received. This review looked at all the stillbirths to see if there were any changes or improvements that our maternity service needed to make.

We have said previously that we are determined to learn and change when things go wrong. All cases have been reviewed by senior midwives and obstetricians in the team and presented to the Trust Patient Safety Review Panel. Based on this review, five cases will be investigated in more detail and one case meets the national criteria for review by the Maternity and Newborn Safety Investigations programme (MSNI).

Immediate learning has been identified following the review of each of the cases and has been focused on ensuring consistent best practice in antenatal midwifery care, access to ultrasonography and access to interpretation for women for whom English is not their first language.

Stillbirths are uncommon, but sadly, a small number will occur every year. For a unit of our size, this is around 15, although the number per month will vary. For this reason, it is difficult to assess whether a short-term increase is significant or not. However, given the huge impact of each stillbirth, each case is looked at in great detail.

During the same period sadly, a mother who was booked for antenatal care with the Trust died outside the county. This has been reported to MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) and the Maternity and Newborn Safety Investigations programme (MSNI). The investigation is ongoing. There were no neonatal deaths.

We know that trust is built through listening, honesty, openness and action and we are here to listen to you. You can share your experience with us in several ways.

If you have concerns about how an investigation was handled or would like to talk further, please send one of our team a direct message with your details so we can follow up with you directly and sensitively.

If you are currently pregnant and are worried or concerned, speak to your named midwife.

Our Patient Advice and Liaison Service (PALS) team are also here to support our patients, relatives and colleagues by discussing their experiences and helping to resolve concerns.

The Maternity and Neonatal Independent Senior Advocate service provides an independent and confidential service in Gloucestershire to support families who have experienced adverse outcomes. You can contact Joanna directly or ask a healthcare professional to do this for you.

You can share your experiences with Gloucestershire Maternity and Neonatal Voices Partnership, which gathers and shares feedback anonymously.