Gloucestershire Hospitals NHS Trust Maternity Review Finds Nine Baby Deaths “Potentially Avoidable”

A new external review into maternity services at Gloucestershire Hospitals NHS Foundation Trust (GHFT) has revealed that nine neonatal deaths between 2020 and 2023 may have been avoidable.

The review, commissioned by the Trust following an “inadequate” rating from the Care Quality Commission and a BBC Panorama investigation, examined seven maternal deaths between 2017 and 2023 and 44 neonatal deaths between 2020 and 2023.

While the majority of cases were found not to have been avoidable, the report concluded that nine neonatal deaths showed “missed opportunities” in care which may have changed outcomes.

Key concerns highlighted

Investigators identified a number of recurring issues within the Trust’s maternity services, including:

• Incomplete risk assessments during pregnancy, particularly around reduced foetal movements and growth monitoring.
• Misinterpretation of foetal heart rate monitoring during labour.
• Delays in escalating cases for senior review.
• Inadequate internal investigations, with missed opportunities often underestimated and insufficient external scrutiny.

The review also found that in 2020–21 and 2022–23, GHFT had higher-than-average neonatal death rates compared to similar units across England.

Despite these concerns, the report noted that no recurrent poor practice by individual staff members was identified, and there were also examples of good, compassionate care provided to families.

Recommendations for improvement

The external review made several recommendations designed to improve safety and outcomes, including:

• Enhancing clinical governance and documentation, supported by better digital systems.
• Optimising antenatal risk assessment and strengthening pathways for managing preterm birth.
• Ensuring stronger compliance with national standards in intrapartum and neonatal care.
• Improving postnatal safety netting and neonatal follow-up.
• Strengthening learning from mortality reviews and improving transparency through external benchmarking.

Gloucestershire Hospitals NHS Foundation Trust response

Kevin McNamara, Chief Executive of GHFT, apologised to the families affected, saying:

“We got that wrong and for that I am truly sorry… The reports highlight that for some babies who sadly died, there were gaps in care that may have contributed to their death.”

He added that the Trust has since “invested heavily” in maternity services, recruited more staff, and made improvements to risk assessments and digital access to maternity records.

Our view

Francesca Paul, Partner at Fletchers Solicitors, said:

“We believe these reviews are a real step forward in identifying the systemic issues within maternity services at Gloucestershire Hospitals NHS Trust. It is reassuring to see that some changes have already been made, but what really matters now is that the recommendations are translated into meaningful action. Too many families have already endured avoidable tragedies, and more must be done to ensure no further lives are lost due to preventable failings. There has been real spotlight into maternity care over recent years from the Francis Report in 2013, Kirkup Review in 2015 and the more recent Ockenden reports which have all highlighted similar themes. Now is the time for action to make improvements to maternity care”

Supporting families

At Fletchers, we act for families across the UK who have been affected by poor maternity care. We have one of the largest and most respected Birth Injury specialist teams in the UK. Where investigations uncover failures, it is essential that lessons are learned and changes implemented to protect future mothers and babies. We work to champion better maternity care.

If you or your family have been affected by maternity care at Gloucestershire Hospitals NHS Trust or elsewhere, our specialist team can provide advice and support. We are able to provide compassionate help and guidance on your options and our aim is always to support families through what is one of the most difficult and traumatic times of their lives.

 Read the full report here (PDF) (pages 103-113)