The report highlighted “unacceptable” instances occurring where staff made cruel or insensitive comments to families when they were most vulnerable, including after baby loss.
In one example, a doula, supporting a bereaved mother who had waited a few hours after her waters broke before attending the ward, said the consultant “barked” at them.
“They said, ‘Well, why didn’t you come sooner? Are you stupid?’”, the doula said. “Now, how can you accept care from somebody who is so dismissive of you, and who talks down to you, and is so condescending?”
In another case, a family member described feeling that the staff were incredibly dismissive of their family after baby loss. “They just wanted to get rid of us and nobody really took that time to give us that care really,” they said. “Then as we were leaving, we were told, ‘Make sure you cover his face because you don’t want to upset anybody.’”
2. Black and Asian women facing racism by staff
The investigation found numerous incidents of shocking systemic and interpersonal racism directed at black and Asian women within maternity and neonatal care.
In some instances, Asian women were stereotyped as “princesses”, implying that they were unable to cope with pain and excessively demanding. One community organisation told the investigation that they had heard a hospital staff member say: “The bloody Asian ones just go on and on and on.”
By contrast, black women were described as having “tough skin” and being able to tolerate excessive pain, while being stereotyped as angry or aggressive.
During an evidence panel as part of the investigation, one woman said: “I was begging for help … I was made to feel like I was that aggressive, angry black woman. But that isn’t me.”
Another added: “I feel like, for us black ladies, they feel like we can handle the pain, even when we are complaining we are in pain.”
3. Lack of accountability by NHS trusts in the aftermath of serious incidents
Many families told the investigation that they experienced a brazen lack of transparency, as well as “cover-ups” and defensiveness from NHS trusts in the aftermath of birth trauma and baby loss.
In one instance, one family member said that when they requested their medical notes in paper format, what they received did not match what had been sent electronically previously. “So I can see the amendments made, there is a lot that are redacted,” they added.
Another said: “[The trust] magically handed my solicitors magical notes that reappeared out of nowhere after three years”, which they knew to be inaccurate.
4. Inadequate staffing and resources at every level of maternity care
Maternity staff were found to have been consistently overstretched by their demanding workload, often having to juggle multiple tasks to compensate for staff shortages.
One midwife told the investigation that they were called into a busy delivery suite because it had “gone bonkers”, despite it not being their familiar area. “So we are half the time having to ask people what to do,” they said. “We’re not providing the same service that the delivery suite midwives can do because they know it like the back of their hands.”
Midwives also expressed “embarrassment” at their profession as a result of public scrutiny and criticism experienced, while others struggled with burnout.
Maternity rooms were also frequently seen to be out of action due to leaking roofs and fire hazards, the investigation found, with staff often having to deal with basic repairs which delayed time they could have spent on delivering care.
