Review finds “missed opportunities” in nine baby death cases at Gloucestershire Hospitals NHS Foundation Trust

The review, commissioned by the Gloucestershire Hospitals NHS Foundation Trust board and covering the period between 2020 and 2023, examined 44 neonatal deaths and assessed the quality of care against national standards.  

While the review identified areas of good practice with Gloucestershire Hospitals NHS Foundation Trust’s neonatal services, it also highlighted serious concerns including:

• Delayed escalation and poor foetal monitoring: CTG (used to monitor a baby's heart rate) misinterpretation and delays in emergency caesarean decision-making
• Inadequate documentation: Neonatal resuscitation records were often missing, limiting the ability to assess care quality. These records capture the specific actions taken, such as oxygen delivery, ventilation breaths, intubation, and chest compressions, along with the newborn's heart rate, oxygen saturation, and other vital signs
• Lack of external scrutiny: Internal reviews frequently lacked independent oversight, and action plans were weak or incomplete
• Failures in transfer planning: In several cases, mothers in labour were not transferred to specialist centres despite windows of opportunity and the need for specialist care
• Inconsistent smoking cessation support: Monitoring of mothers who were smokers was inconsistent and referrals to services to help them stop smoking were “inadequate”

The BBC reports that the findings of the external review will be formally presented at the Trust’s Board meeting on 11 September 2025. 

The Trust has been under enhanced regulatory oversight since 2022, including entry into NHS England’s Maternity Safety Support Programme. In May 2024, the Care Quality Commission issued a Section 31 warning notice requiring urgent improvements in leadership and clinical safety.

Leigh Day medical negligence partner Julia Reynolds, who represents families affected by poor maternity care across England and Wales, said:

“Maternity care is facing a crisis across the country – and many families will be incredibly concerned to hear about another review that has identified failings in maternity and neonatal care.”

“Health Secretary Wes Streeting has ordered a rapid review into maternity care in England, and it is vital that the issues highlighted in the review into Gloucestershire Hospitals NHS Foundation Trust – and the reviews just like it into trusts across the country – are addressed as soon as possible.

“I continue to speak to families who have had their lives changed forever by poor care, and it is clear that urgent action is needed to ensure that no other families suffer avoidable harm and such devastating loss.”