Story Highlight
– 58 baby deaths at OUH potentially preventable with better care.
– Bereaved families cite missed opportunities and defensive culture.
– Internal reviews criticized for inadequacy and lack of accountability.
– OUH faces scrutiny amid calls for public inquiry.
– High stillbirth rates and significant complaints about care quality.
Full Story
At least 58 infants at the Oxford University Hospitals Trust (OUH) maternity unit may have had a chance of survival if their care had been better, according to a recent investigation conducted by the BBC. The analysis revealed a heartbreaking total of 32 stillbirths and 26 neonatal deaths—deaths occurring within the first 28 days of life—between 2019 and 2024, as uncovered through a Freedom of Information request. Families affected by these tragic incidents have expressed their grief over missed opportunities for intervention, citing potential shortcomings in communication and a culture of defensiveness among senior medical staff.
In response to the findings, a spokesperson for OUH expressed regret over the distress experienced by some families, stating, “We are sorry that some mothers feel their experiences have not been what we would wish.” The trust insisted that all reported baby deaths have undergone rigorous reviews to determine the circumstances and identify areas for improvement. Moreover, it clarified that some cases involved mothers who were referred for specialist care from other regional hospitals.
Eleanor Taylor-Verlaan, who is scheduled for a Caesarean section next month, shared her heartbreaking experience of losing her first child, Alissa, in 2017. Alissa was born with severe brain damage due to a lack of oxygen following complications when the placenta detached from the womb. Eleanor recounted her belief that had her care been managed better, her daughter could still be alive. “They should have seen me as soon as I turned up to hospital because I was classed as high risk,” she said. Despite her earlier scans indicating risks such as growth restriction and stillbirth, her monitoring was insufficient.
During her pregnancy, Eleanor experienced abdominal pains and nausea but was advised by midwives to manage her symptoms at home with paracetamol. On 20 February 2017, after more than two hours of waiting in the maternity assessment unit, she underwent an emergency Caesarean section, but her daughter passed away shortly after being born. An internal review conducted by the trust noted some deficiencies but concluded it was improbable that these would have changed the outcome for Alissa. Now, Eleanor wishes to pursue an independent inquiry into her case to challenge the findings.
Laura Cook, a partner at the legal firm Medilaw, pointed out issues with the internal review processes at OUH. “It feels like a tick-box exercise to avoid accountability,” she noted, suggesting that families often must resort to legal representation to uncover the truth behind tragic outcomes. She also highlighted a notable defensiveness from OUH, contrasting it with other trusts.
OUH acknowledged that some families are still unhappy with their experiences and asserted that patient feedback is taken seriously. The BBC’s investigation further revealed that a total of 27 baby deaths and two maternal deaths from 2019 to 2025 were subject to external investigations by the Maternity and Newborn Safety Investigations (MNSI), which highlighted critical safety recommendations. These included improvements in monitoring guidance, oversight, and communication within the trust.
Financially, OUH has responded to past incidents, with over £72 million paid in obstetrics compensation from 2020 to 2025. For context, this figure stands in contrast to Nottingham University Hospitals Trust, which has faced significant scrutiny and paid approximately £61 million. While OUH claims that its claims rate per birth is among the lowest for similar trusts dealing with complex cases, concerns continue regarding the implications of compensation figures tied to historical incidents.
From 2019 to 2024, OUH conducted 361 internal reviews of baby deaths through the Perinatal Mortality Review Tools. Of these cases, at least 58 were rated as possibly preventable, leading to concerns about the level of care provided. Additional investigations by the BBC indicated parallel circumstances in Leeds and Sussex, where numerous baby fatalities also raised alarms about preventable deaths across the NHS.
The Care Quality Commission (CQC) has empowered itself to prosecute trusts due to serious care failures since 2015; thus far, five such prosecutions have occurred. In a separate but related case, Alice Topping described her struggle within the system after being identified as high-risk at her 20-week scan and later facing barriers to securing vital additional scans for her baby. Following a long series of unsuccessful attempts to book an appointment, Alice’s daughter, Smokey, tragically died during labour in September 2023. An internal investigation cleared the trust of wrongdoing, while an independent review revealed a series of critical failings that could have altered the outcome for her family.
Alice expressed her disbelief that straightforward care procedures were overlooked. “At the most vulnerable time in my entire life I was failed… it’s just horrific knowing that with just basic care my daughter should be here,” she lamented. The findings have further fuelled calls for accountability, as “bereaved and harmed families deserve answers, truth, and change,” she added.
Despite these controversies, in 2023, OUH recorded the highest stillbirth rate among 25 similar trusts treating high-risk pregnancies. Recent reports from MBRRACE-UK indicated a slight dip in the stillbirth rate for OUH, which nonetheless remains a significant concern given their volume of annual deliveries.
The CQC had previously inspected the John Radcliffe Hospital’s maternity unit and downgraded its rating from ‘Good’ to ‘Requires Improvement’ over numerous allegations of bullying and poor team dynamics. To address ongoing issues, OUH is currently receiving targeted support from NHS England, with an aim to bolster decision-making processes and enhance overall care quality, particularly around induction of labour.
A growing number of advocates are now demanding a public inquiry into OUH, highlighting the need for institutional accountability. Health Secretary Wes Streeting has authorised independent investigations into other trusts, but the call for similar scrutiny at OUH remains unanswered. Michelle Welsh MP, chairing the All-Party Parliamentary Group on Maternity, underscored the urgent need for action, stating, “There is a systematic toxic culture that needs tackling.”
With a national review of maternity services due to conclude in June 2025, there is hope for significant reform. A spokesperson for the Department for Health and Social Care stated that a framework will soon be established to improve care across England.
Simon Crowther, interim chief executive of OUH, acknowledged the tragic nature of the families’ stories revealed during the investigation. He reassured that the trust is committed to learning from experiences and aims to enhance the safety and quality of maternity care provided.
Our Thoughts
The investigation into Oxford University Hospitals Trust (OUH) highlights multiple failures in maternity care that resulted in the tragic deaths of at least 58 babies. Key lessons include the necessity of improved communication, timely monitoring, and adherence to safety protocols for high-risk pregnancies. The NHS should have provided more vigilant oversight and responsiveness to concerns raised by midwives and patients, in line with the Health and Safety at Work Act 1974, which mandates the duty of care to ensure the safety of patients.
Regulatory breaches include deficiencies in risk assessments and clinical oversight, violating the Care Quality Commission (CQC) standards for safe care and treatment. Additionally, internal reviews appeared not to adequately address care shortcomings, reinforcing a culture that prioritizes reputation over accountability, contrary to the principles set by the Health and Social Care Act 2008.
To prevent similar incidents, systematic changes are essential, including rigorous external investigations, comprehensive staff training in communication, and the establishment of a more transparent feedback mechanism. Implementing these measures could significantly enhance the safety and quality of maternity care in the NHS.
