NHS maternity care scandals are 'not isolated to one or two trusts' and are happening nationwide

The Care Quality Commission has found baby death or injury incidents were not learned from as Health Secretary Wes Streeting said it was a "cause for national shame"

NHS maternity care scandals are not isolated to one or two trusts and are happening across the country, the regulator has found.

Baby death or injury incidents are poorly managed and not learned from, according to the Care Quality Commission, which raised concerns "about the potential normalising of serious harm in maternity".

The CQC's 16-month investigation targeted maternity units not inspected and rated since March 2021 – those it had been least worried about. Two-thirds of the services either 'require improvement' or are 'inadequate' for the safety of mothers and babies. The regulator called for "increased national action" and ring-fenced investment to tackle the shortfalls.

Health Secretary Wes Streeting said: “These findings are cause for national shame. Women deserve better - childbirth should not be something they fear or look back on with trauma.”

The CQC identified problems including staff shortages, problems with equipment, including call bells not working and poor pain management. It also found delays to emergency Caesareans, because operating theatres were unavailable, as well as cramped, noisy and overheated wards. Overall, 48% were rated as inadequate or requiring improvement with around a quarter receiving a lower overall rating than when last

inspected. On the single issue of safety, 65% were judged to be failing.

NHS maternity care has been under increased scrutiny in recent years after several high-profile inquiries, such as the Ockenden Review into more than 200 baby deaths at the Shrewsbury and Telford Hospital NHS Trust, and the investigation into maternity services in East Kent. The report said: "Many of the factors apparent at East Kent and Shrewsbury and Telford are more widespread. Key issues continue to impact quality and safety - and disappointingly, none of them are new."

Nicola Wise, director of secondary and specialist care at the CQC, said: "Sadly, our latest maternity inspection programme has further evidenced the need for urgent action with continued problems indicating that the failings uncovered in recent high-profile investigations are not isolated to just a handful of individual trusts.

"Although we've seen examples of good care and seen hardworking, compassionate staff doing their best, we remain concerned that key issues continue to impact quality and safety. Disappointingly none of those issues are new."

Other issues highlighted were inconsistencies in the way safety incidents were monitored and recorded, including major emergencies such as significant loss of blood and internal injuries recorded as causing low or no harm. The report highlighted bad leadership and management creating blame cultures and low morale. Of the 131 units inspected as part of a national programme between August 2022 and December 2023, almost half (48%) were rated as requires improvement or inadequate. Only 4% were classed as outstanding and 48% were rated as good.

NHS England’s chief midwifery officer Kate Brintworth said: “Despite the hard work of NHS staff, we know that, for large numbers of women and families, NHS maternity care simply isn’t at the level they should expect and there is a lot to do to improve. We know there is much more we need to do to drive up standards of care and build on improvements already made, and we will continue to provide intensive support to the most challenged trusts and support a growth in the maternity workforce.”