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​UK Birth Trauma Inquiry​

Report written by ​By Emma Trudgill – Midwife analyst – UKEM.

APPG Public Birth Trauma Inquiry 

Medical negligence in childbirth  

Resulting in litigation settlements estimated at £1.1bn a year 

A weathered system  

Leading to a profoundly concerning disparity in maternity care where there is a continued increase in ethnic minority mother and baby deaths  

Three major inquiries since 2015  

Despite the poignant testimonies and recommendations for change, we find ourselves in the same situation 

The Montgomery ruling 

At UKEM, our observations reveal a recurring pattern of insufficient or entirely absent consent in the claims we have encountered. 

The landmark Montgomery ruling emphatically stresses the importance of disclosing intervention and delivery risks to patients, tailored to their individual concerns and preferences. Regrettably, numerous instances have emerged where informed consent was overlooked, with women expressing that had they been apprised of the relative risks, they would have chosen differently. Our own investigations align closely with the narratives shared in the APPG report, and we wholeheartedly support the recommendations arising from it. 

The Review

‘Mistakes and failures’ 

The report underscores the impact of errors made by maternity staff, resulting in tragic outcomes such as stillbirths, premature births, hypoxic events affecting infants, and secondary cerebral palsy, alongside enduring physical and emotional injuries to mothers.  

It is evident that maternity services are grappling with chronic understaffing, exacerbating the challenges of delivering safe and high-quality care, a goal we collectively aspire to achieve for all mothers. Presently, the testimonies paint a distressing picture of negligence, where the lives of both mother and child are at stake. The increasing number of birth trauma inquiries reflects a concerning trend, revealing systemic shortcomings in care delivery that are deeply troubling to confront. The voices of the women we have engaged with, as well as adult children pursuing birth-acquired brain injury claims, echo many of the sentiments articulated within the report. 

A call to overhaul maternity care 

The findings of the recent inquiry into traumatic births shed light on a deeply concerning reality within maternity care. Stories of stillbirths, premature births, birth injuries, and profound emotional distress among mothers and partners underline the urgent need for systemic change. It’s evident that too many women have endured neglect, mistreatment, and a lack of compassion during what should be one of the most significant moments of their lives. As we reflect on these harrowing accounts, we must recognize the imperative for immediate action. 

This inquiry serves as a clarion call to overhaul our maternity care system, placing women and their well-being at the forefront. We cannot allow poor care to become the norm, nor can we continue to disregard the emotional and physical needs of mothers and their partners. It’s time for comprehensive reform, guided by compassion and empathy, ensuring that every woman receives the respect, dignity, and support she deserves during pregnancy, childbirth, and beyond. Let us heed these stories as a catalyst for change, advocating for a maternity system that is truly woman-centred, where every birth is treated with the care, sensitivity, and expertise it demands. 

Client quotes 

Anonymised and confirmed as accurate within the records reviewed. 

​‘I was left on the monitor contracting every few minutes. The midwife didn’t come back for 4 hours and then shouted at me when she looked at the monitor why I hadn’t called for anyone’. 

​‘I had no contact to support me after the death of my baby. I later found out that this was because I didn’t speak English and the staff weren’t sure how to arrange translation as an outpatient’. 

​‘I told the midwife I had a headache for 3 days. She found protein in my urine. She said it was unlikely to be pre-eclampsia and told me to drink more. My daughter suffered HIE and CP from antenatal placental insufficiency caused by untreated Pre-eclampsia’. 

​‘I attended triage 4 times in the fortnight before my baby was born, with abdominal pain in waves and brown loss. 2 of those I didn’t even have a CTG. I asked for an early labour test and was reassured I didn’t need one. My baby was born at 28 weeks after a spontaneous labour. She is non-verbal, needs a wheelchair fulltime and is completely dependent on me. My marriage ended due to the stress of it all’

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