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Disclosure Season 8 Episode 8
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00:00Maternity care under strain like never before.
00:07They let that girl down in the most horrific way.
00:10A system creaking under pressure.
00:12Things can go quite abruptly and very catastrophically wrong.
00:17Mums and babies being put at risk.
00:19I knew he was really sick and nobody listened to us.
00:22They failed Freya. They failed us.
00:24We hear from midwives on the inside.
00:26Most days I feel absolutely terrified.
00:29There's no capacity in labour ward to take them.
00:33There's not a midwife to take them.
00:35And ask are we doing enough to keep women and babies safe?
00:38Women's experiences are deteriorating and staff are very stressed.
00:45That is a pretty lethal combination.
00:48People need to see what's actually going on
00:51and to understand that things do need to change.
00:59She was a delight to be loved by and to love.
01:11St Andrew's peer, Laurie and his wife Jackie came here on their wedding day.
01:16A year later, the couple were expecting their first child.
01:20It was a pleasure to see her bloom.
01:26And you could see she just grew.
01:29It grew into wanting to become a mother.
01:34So excited. Just everything.
01:36A week before her due date, Laurie says that Jackie raised concerns
01:40about their baby at a routine midwife appointment.
01:43It felt that there wasn't as...
01:46The kicks weren't as strong, that the movement wasn't as prominent.
01:51I think she'd said she felt more like the baby had moved
01:54rather than the baby moving.
01:57Laurie says the midwife reassured Jackie.
02:00The following morning, still concerned,
02:02the couple went to Ninewell's Hospital in Dundee.
02:05The consultant, she came in and pretty much,
02:10as soon as the machine went on Jackie's stomach,
02:14she announced,
02:16that I'm so sorry.
02:22And we found out that it was...
02:25I'm going to be a little girl.
02:29And we talked a few names and settled on Olivia.
02:36Jackie was told she'd have to give birth to their baby girl stillborn.
02:40In the maternity unit, she was given a hormone pessary to bring on labour.
02:45Within hours, she was having intense contractions.
02:48It was one right after the other, right after the other.
02:52She could barely concentrate to keep a conversation.
02:57She stands up, she slumps in my arms.
03:03I thought she'd fainted.
03:05Everyone thought she'd fainted.
03:07At which point they had to then call the crash.
03:10The patients collapsed.
03:13Everyone then runs in.
03:16As soon as they get out into the corridor, Jackie has a cardiac arrest.
03:22They did everything that they could in the emergency resus.
03:28And, unfortunately, they just...
03:31They couldn't...
03:32They couldn't bring her back.
03:34Um...
03:35And...
03:38I was just left wondering what on earth just happened.
03:44In 24 hours, Laurie had lost his baby and his wife.
03:49In the aftermath of Jackie's death, Laurie began to piece together information from the health board.
03:54He discovered Jackie had been given eight times the recommended dose of the drug to bring on labour.
04:00In Jackie's medical notes, there is no mention of that drug error at all, at any point, until after she's declared dead and passed.
04:16It emerged that some staff were aware of the drug error before Jackie had even gone into labour.
04:21Not going to Jackie, their patient, and saying, we have messed up.
04:25Like, there would have been opportunity to have removed that drug.
04:31It may not have altered events going forward, but it might have, and it was a decision that Jackie should have been given.
04:42An internal investigation found the drug overdose was likely to have contributed to Jackie's death.
04:48A later fatal accident inquiry said it was possible, but not probable, her death could have been prevented if she'd been given the correct dose.
04:55After the death, Laurie says the health board was not forthcoming with the answers he needed.
05:02Even if Jackie couldn't have been saved, the grief and torment that myself and Jackie's family and my own family have gone through,
05:13to just get answers and a modicum of understanding, like, it's just, it's unacceptable, you know.
05:20It's been five years since Jackie's death.
05:24Earlier this year, NHS inspectors issued 20 requirements to improve safety at Ninewell's Hospital, where Jackie died.
05:32While they found instances of good care, they pointed to issues with staffing, inconsistencies with note-taking and learning from adverse events.
05:40It's these same issues that come out. To me, it just speaks of this culture of indifference to patient care.
05:46NHS Tayside said it was deeply sorry for Laurie's loss.
05:51It says it undertook a number of internal investigations and engaged in external reviews following the deaths of Laurie's wife and child.
06:00All recommendations were fully accepted.
06:03It said that as a result, our systems and processes have been strengthened and improvements have been made to how we provide care.
06:10The report into Ninewell's was the first unannounced inspection of a maternity unit in Scotland.
06:20Elsewhere in the UK, high profile investigations have uncovered widespread failings around four key themes, staffing issues, poor culture and a failure to listen to families or learn from mistakes.
06:33Yet there's been relatively little scrutiny of maternity care in Scotland.
06:36I think Scotland is the same as the rest of the United Kingdom. I think we have the same issues from the north of the UK to the south of the UK.
06:46Dr Helm McTeer is a doctor who specialised in the care of the sickest newborn babies and has been involved in key investigations into care across the UK.
06:54Everybody who has a baby in Scotland should be able to expect compassionate and courteous care.
07:01Mary Renfrew is a professor of midwifery who led a major review into maternity care in Northern Ireland.
07:07There are real challenges at the moment and I think we've really got to step back, take stock and say we're not doing the best job we can in the UK right now.
07:19I think probably so many of the things that are happening for women and babies and families in Scotland resonate with what's happening across the country.
07:30Every year in Scotland around 45,000 babies are born.
07:36Maternity care isn't just about birth.
07:39It's about the entire journey through pregnancy and the weeks that follow.
07:44For most, it ends with a healthy baby.
07:46But over the last 12 months, families across Scotland have told us that they've been let down by a system that should be keeping them safe.
07:57We feel really nervous about going into hospital, like really anxious to obviously have another baby.
08:04It's August. Julie and Angus are getting ready to have their third child.
08:08We're up all night worrying about what's going to happen. Is anything going to go wrong?
08:14It is just terrifying and it should be an exciting time for us, but I feel that's been taken away from us now.
08:20The couple's first baby, Mason, was born in January 2023 at Princess Royal Maternity Hospital in Glasgow.
08:27I feel like everyone tells you, like, no one prepares you for that and you're like, yeah, yeah, yeah. But when it actually happens, you're just, just filled with a different kind of love.
08:35When he was born and he was a little boy, like, I just, I couldn't believe it. Like, he was just perfect. He was amazing.
08:41Just a day old, Julie and Angus brought Mason home from hospital.
08:46The next day, they started to worry about him.
08:50There was like a real massive change in him. He was really lethargic. He wasn't waking up.
08:54And he was quite jittery, wasn't he?
08:58After routine checks, the community midwife decided Mason didn't need readmitted to hospital.
09:03We felt completely helpless. We didn't know what to do. We had a baby at home who couldn't feed.
09:08We didn't know how to make him feed.
09:10Still worried, hours later, Julie called the maternity unit where she'd just given birth, but was told they could only help mums and couldn't take Mason.
09:17Desperate for help, the couple went to the emergency department at the Royal Children's Hospital in Glasgow that night.
09:25It was so, so cold at this point. I didn't know this at the time, but they were unable to get a temperature from him.
09:32They just marked his temperature as 35.
09:33But didn't tell us about any of this, so we were just told that everything was okay.
09:39Staff recorded Mason's temperature incorrectly and his records were incomplete, meaning staff failed to recognise how sick he was.
09:47Mason had hypothermia, but equipment wasn't sourced to heat him up.
09:52And key tests were missed that would have indicated Mason had a life-threatening infection.
09:56It was the most basic nursing care, and they would have known how sick he was.
10:03Julie is an intensive care nurse, so is used to emergency situations.
10:07Obviously, when I think back, I think, why did I not notice that at the time?
10:11But at the time, he was just so, so cold, and I was trying to keep him warm.
10:17The errors in Mason's care continued.
10:19After three hours in A&E, Mason was transferred to the neonatal unit, but critical information wasn't passed on.
10:27Again, at several points, staff failed to recognise how sick he was. Monitoring and key tests were missed.
10:33He let out, like, a gasp. Like, I really, like, I always remember it.
10:37I think it was his last breath. And, um, Angus asked the doctor, like, is he still breathing?
10:43Just something in my head said this is wrong, like, something bad's happened.
10:49She couldn't get bloods, and then that's when she realised that he actually wasn't breathing.
10:53And that's when she just went into total panic.
10:57In this critical situation, staff struggled to get vital equipment to work.
11:01They tried to resuscitate Mason for 30 minutes.
11:04I asked the healthcare assistant if he was still alive, and she said yes.
11:08He's still alive. They're working on him. I thought, oh, thank God.
11:11And then the doctor came in and she just said, there's nothing else we can do for him.
11:17Baby Mason died at 10 to midnight, six hours after he'd been admitted to hospital.
11:23His death was caused by feeding issues and sepsis, both of which an internal review found could have been treated.
11:29It also found failings across the system and multiple missed opportunities which could have prevented Mason's death.
11:35I knew instantly there was something wrong with Mason.
11:40I knew he just had this complete change in him, and I knew he was really sick, and it's not good enough to say, oh, well, this shouldn't have happened.
11:49It's incredibly important that services in the community, in the hospital, in pregnancy, in labour and birth, in postnatal care, in neonatal care, all talk to each other.
12:03Everybody has to be on the same page.
12:05But a lot of the time, services are very fragmented, and that fragmentation is a risk for women.
12:15For services to work well, they need the right staff with the right support.
12:19But some say the situation on the front line is critical.
12:23Edinburgh Royal Infirmary is one of Scotland's busiest maternity hospitals.
12:28More than 5,000 babies are born here every year.
12:31For the last 12 months, we've been in contact with members of staff working at the unit.
12:36I'd say most days I feel absolutely terrified. Absolutely terrified.
12:41Last year, BBC Scotland was shown a whistleblowing report that found a toxic workplace culture and staff shortages had led to harm coming to mothers and babies.
12:52Since then, staff say problems are still widespread.
12:56A number of midwives wanted to take part in this programme, despite the risk to their jobs.
13:01We're using actors to voice their words.
13:04It's so destroying.
13:05Sorry, I'm going to get upset.
13:12You're just fighting fires all day.
13:15The whole shift.
13:17Which builds on you, and eventually, you just found out.
13:23And in the end, I just thought, I can't go back.
13:26The midwives say they're regularly working with dangerous staffing levels.
13:30On Labour Ward, there should be 12 midwives on a day shift and 11 out of hours.
13:34I was on at the weekend, and there was only five of us.
13:38So, that's standard.
13:42You should always be in the room if you've got a labouring patient.
13:45But more and more frequently, I can't do that, because I've got to come out of the room to go and deal with somebody else.
13:50Short staffing means midwives can't give the care they want.
13:54We're delivering women on the antenatal ward because we can't get them round to the labour ward.
13:57We shouldn't be delivering babies in four-bedded bays with other women with a curtain just pulled across them.
14:06It doesn't matter how experienced you are.
14:09If you get to that saturation point where there is just too many patients and not enough staff, there's only so much you can do.
14:16The strain on the unit is leading to delays starting treatment. Women are waiting too long for inductions.
14:23That's a process that helps bring on labour if there are concerns about the baby.
14:28We tell them that we have to bring you in and induce your labour.
14:32Bring on your baby's birth quicker because you might contract an infection that could kill you.
14:37And then we bring them in and we do nothing.
14:40Like, we can't justify keeping them there for three days and telling them that that's okay.
14:46And that's because of staffing.
14:48There's no capacity in labour ward to take them.
14:51There's not a midwife to take them.
14:53The midwife say they've tried to raise concerns to senior managers.
14:57I've voiced many concerns to levels above the last few years.
15:02They have fostered a culture, a toxic culture of them being in control.
15:07They make it so that the staff are scared to speak up for fear of repercussions.
15:13We've spoken with a number of families who feel delays and staffing issues have caused harm.
15:17The midwife say staffing problems and poor relationships with senior management make it hard to keep women safe.
15:24I feel I'm not being truthful with the women and their families when I tell them they're safe and this is the safest place for them.
15:31I don't always feel like it is.
15:32NHS Lothian told us whistleblowing concerns are being taken extremely seriously and that wider matters such as staffing, recruitment and working culture will take time to resolve.
15:46It's said that significant investment and improvements have already been made, but there's still more to do to ensure our staff feel supported at work, safe to raise concerns and able to thrive.
15:57The challenges in Edinburgh are not unique. Staff elsewhere have described similar problems.
16:02I think it's pretty obvious in labour and birth that if systems are stretched, then the care that women are going to need in there is not going to happen.
16:14One-to-one care in labour is really important, but that is virtually impossible to provide in the current system.
16:21So you're going to potentially miss things or rush things. And again, that's a risk to women.
16:28Maternity care is becoming more complex with older first-time mums, more obesity and other health conditions.
16:35We're seeing much, much higher rates of intervention, particularly in labour, higher rates of induction and much higher rates of caesarean section.
16:43So if we have a higher caesarean section rate and if we have a more at-risk maternity population, then that is going to be more expensive and more resource-requiring in the maternity services and also in the neonatal services.
17:00So we have to be tracking what's happening and having our resources match what's happening.
17:08There are high vacancy and absence rates for midwives across Scotland, just at a time when serious injuries during childbirth are on the increase.
17:16Women's experiences are deteriorating and staff are very stressed. That is a pretty lethal combination. So at every point we've got to really evaluate, not just the clinical safety, important as that is, but the psychological safety, the mental health and wellbeing.
17:36In Scotland, there's little published information about how well our maternity services are working. Only Ninewells has had an inspection report published with another due into Edinburgh.
17:49Other evidence can be found in Fatal Accident Inquiries, which investigate some of the most serious cases where a death has occurred.
17:57We feel they obviously failed us when it came to Freya. They failed Freya. They failed us.
18:02In May this year, a sheriff said staffing should be reviewed at a Glasgow hospital after the death of Freya Murphy. She was seven days old when she died in 2018, with significant brain injuries and organ damage.
18:18We went to the hospital very late on a Friday night and she was then born on a Saturday morning.
18:26We were not told there was anything to worry about during the whole labour until the moment Freya was born.
18:35Martin and his wife Karen arrived at the maternity unit at the Queen Elizabeth University Hospital on an extremely busy Friday evening.
18:44There was a shortage of midwives and a high number of patients needing care.
18:47We went to a waiting room and nobody had examined her for over two hours.
18:55But when I went to ask if somebody could have a look at her, the reply was, she's a first time mum, she's probably not even in labour.
19:02And it was when we insisted, they then found out that she was over six centimetres dilated.
19:08The inquiry found failures to realise that baby Freya was in distress. There was a delay in Karen being fully examined once in the labour ward.
19:19That examination would have established that Freya needed to be born urgently.
19:22Due to pressing issues, the consultant decided not to do a full examination. She did one by sight. If it was done at the time, then another pathway would have had to have happened and that would have led to Freya being born earlier.
19:39Karen should have been taken to the operating theatre for delivery, but only one was available. It emerged there were not enough staff to open an additional theatre on a weekend.
19:48It transpired that there's three theatres available, but they only had staff for one theatre.
19:55When Karen and Freya required treatment, the theatre that they had staffed for had already been allocated.
20:03The sheriff said maternity wards should be adequately staffed on evenings and weekends.
20:08If a baby is born Monday to Friday 95, they have a better chance because there's more of a medical team available.
20:15It needs to be looked at how people are at a disadvantage if their child is not born during business hours.
20:26The inquiry couldn't determine whether Freya's death was preventable, but said had she been born earlier, she would have had a better chance of survival.
20:34Your wife isn't here with you today doing this interview. Why is that?
20:38Karen suffers from anxiety and PTSD. She relives it constantly. And she just felt that it's so hard for her.
20:51It was really my... I still feel as if I need answers.
21:00And the impact on you?
21:02Massive. Everything. Friendships. Career. Family. It never goes away.
21:09Even we try very hard not to let it affect our other children, but it's a part of their life as well.
21:21Greater Glasgow and Clyde Health Board apologised to the family of baby Freya for the distress experienced.
21:27It said it fully accepted the fatal accident inquiry's recommendations and these were implemented.
21:34It said its workforce plan prioritises maternity services and is reviewed annually to ensure ongoing safety and quality of care.
21:42And added, we continually monitor and adjust staffing levels to ensure safe, effective maternity care across all sites.
21:50It took nearly seven years for the fatal accident inquiry to publish its findings into Freya's death.
22:00Julie and Angus are waiting to find out if prosecutors will investigate Mason's death.
22:06After Mason died, that's obviously was the most heartbreaking thing that could ever happen to you.
22:13We're just really wanting this to never happen again.
22:15When something goes wrong, the health board should first carry out its own internal investigation.
22:21This is called a significant adverse event review.
22:24The NHS review into Mason's death took two and a half years.
22:28It found multiple failings in his care.
22:31All the mistakes that were made, you just think the mistake's going to happen again.
22:35And we feel like there's a lot of people that done a lot of things wrong that should never ever happen in health care.
22:41And it just to us feels like a complete whitewash.
22:43Julie and Angus say they've had to fight constantly for proper scrutiny into what's happened and to have their voice included in the review.
22:51They say there's still unanswered questions.
22:54The system, the process is just so flawed.
22:57They say they've got the families in the heart of it, but they make you feel like you're a nuisance.
23:01You're trying to put faith that they're going to try and do their best to get to these answers.
23:08But it just felt the more that it went on, the less information you were getting back.
23:13They weren't seeking answers for the sake of understanding or uncovering these truths.
23:19They were doing it because it was a requirement of process.
23:22Maternity investigations elsewhere in the UK have all found a failure to listen to families.
23:29And this is echoed by those we've spoken to for this programme.
23:31At the end of the day, what families want is an open and an honest account of what happened.
23:39They want an apology and an acknowledgement when it has not gone as it should have done.
23:45They just want to be treated with dignity and with respect and in an honest and an open and transparent way.
23:51Is it concerning to you that actually every single family that we've spoken to for this programme has said that they felt that they were not listened to?
23:59I think that's, yes, that is concerning.
24:02I think we get so tied up in protocols and systems and processes that we actually forget to use our ears and listen to what the patient's telling us.
24:11Yes, we have to listen to families.
24:14NHS Greater Glasgow and Clyde expressed condolences to the family of baby Mason.
24:19They told us, we value the importance of the voice of parents and carers and include this in our assessment process.
24:27They said there were some missed opportunities for care and we're very sorry for this.
24:32That a new infant feeding guidance was being created and they'd updated neonatal guidance on many aspects of care,
24:40including pathways, monitoring temperature and observations.
24:43In 2023, Dr McTeer carried out a review of neonatal deaths in Scotland.
24:51It came after spikes and the number of babies dying in their first month of life.
24:56No single reason for the increase in deaths was found, but Dr McTeer says there were significant gaps and variation in the way health boards were investigating poor outcomes for babies.
25:06I think in common with other reviews across the UK, we find that CS adverse event reviews are not always undertaken quite as thoroughly as they might be.
25:18And that the learning from these reviews is not always made. And then if the learning can't be taken from them, then of course that learning can't be disseminated.
25:27There have continued to be spikes in the number of newborn babies dying since that review was carried out.
25:34Scotland is the only part of the UK where there's not been a recent or ongoing review into maternity and neonatal services.
25:42The midwives and the families we've spoken to for this film are calling for that to happen.
25:46Jackie's story could slot very easily in the headline of any of those review cases. This is a failing that I think is, at this moment in time, uncovered in Scotland, but it's definitely there.
26:06People need to see what's actually going on and to understand that things do need to change.
26:12There's no point in doing a review if it's just going to be a bit of paper and then nothing comes from it. It needs to be, if there's a review, there needs to be change.
26:21What we have to tackle are the systemic issues that will improve care. We need to tackle proper data and looking for early signals of things going wrong.
26:31We need to tackle team working. We need to tackle open and honesty and open review of cases, organisational issues.
26:40How vital is it that we do that and we do that urgently?
26:44It's absolutely crucial. It's absolutely crucial.
26:49I would say that all is not lost. I would say it's as critical as I've ever seen it.
26:55But there are real strengths and I think those real strengths are the staff.
27:02We need, in Scotland, the boards genuinely to give maternity care the priority that it needs.
27:11We need the political will to support that.
27:13We asked the Scottish Government for an interview but were told no minister was available.
27:19Instead, in a statement, Women's Health Minister Jenny Minto said they were committed to learning from every case of death or injury to improve care and strength and safety.
27:28They would continue working closely with NHS boards and said a set of national standards for maternity care were expected to publish shortly.
27:38We've spoken to families who say they've had amazing maternity care in Scotland, with hundreds of babies born safely every week.
27:50But it's clear that there are real pressures on a system that's not doing enough to keep mums and babies safe.
27:56Julie and Angus have had their new baby. It's a little boy called Clark Mason McLean in honour of his big brother.
28:07And while their family has grown, the loss of Mason is always with them.
28:12Every step you think, oh, he should be here. Like, he should be at the park, he should be being cheeky, he should be playing with his little sister, he should be doing absolutely everything.
28:21We should have had these moments where we're missing.
28:24We should have had these moments where we're missing.
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