In 2023/24 (1 April – 31 March) the PHSO investigated 87% more cases (28) about maternity care than the previous year (15). These are all cases which have already been investigated by the NHS and where they failed to address concerns. The ombudsman recently closed a case in which it found a catalogue of failings by a hospital led to the death of a baby girl who was stillborn in December 2018.

In the cases investigated issues identified included delays to treating infection and carrying out an MRI scan, failing to manage an epidural during a caesarean, and lack of consent for a procedure. Since April 2020, PHSO has carried out 80 detailed investigations related to failings in maternity care. Investigations concluded in 2023/24 account for more than a third of these.

During that time the number of investigations upheld or partly upheld has also increased.

Rebecca Hilsenrath, parliamentary and health service ombudsman, said: ‘There have been successive inquiries and reports into maternity care and no real evidence of change. We need to see lessons being learned. Our 2023 report found the safety and wellbeing of women is being put at risk due to the same mistakes being repeated.

‘We know that there are brilliant practitioners out there, but when maternity services fail, families are left with trauma and tragedy. The NHS needs to take steps to share good practice and change what isn't working.'