Nottingham maternity care scandal review: what are the key findings?

1. Failures in maternity and neonatal care were ‘systemic, deep-rooted and sustained over many years’ At every stage of care received from the trust, from antenatal to postnatal, mothers and their babies were subject to deep-rooted and systemic issues. There were repeated failures to accurately report, grade and investigate serious occurrences, resulting in severe harm or even death to mothers and their babies, while such instances were routinely downgraded or dismissed as “unavoidable” to escape external scrutiny and protect the trust’s reputation. A significant number of stillbirths, maternal deaths and severe complications could have been avoided if the care provided had been adequate, the report found. As regards the 462 stillbirths reviewed, about one in five of the case reviews of the mothers were graded 2 or 3, meaning significant or major concerns were identified in the patient’s care. Similarly, of the 27 maternal deaths reviewed, suboptimal care was identified in about a fifth (21.4%) of these cases. The review also found a high number of mothers who received care from the trust experienced serious and severe complications. There were 142 cases of fourth-degree perineal tears, 130 unexpected admissions to the intensive care unit (ITU), 115 cases of massive obstetric haemorrhage and 76 cases of severe pre-eclampsia. Of the mothers who were admitted to intensive care, more than a third (35.6%) experienced care that was graded suboptimal. 2. …