Bereaved parents in call for nationwide inquiry into maternity services

Parents who lost their babies in Scotland’s hospitals are demanding a nationwide inquiry into maternity services as they warn of a “toxic culture” that has “shielded and protected” failings in the NHS “for years”.

Julie Keegan, an ICU nurse whose three-day-old baby died after failings at NHS Greater Glasgow and Clyde (NHS GGC), claimed a lack of accountability meant “nobody ever faces consequences” in the NHS, even for serious errors.

“These people are letting our babies die – and they’re going to work the next day,” she told the PA news agency during a visit to the Scottish Parliament.

Ms Keegan and her partner Angus McLean joined Lori Quate, whose daughter died in his wife’s womb in 2020 a week before she was due to give birth. Jacqui Hunter, who was 39, died less than 24 hours later.

She died from an amniotic fluid embolism, a rare and life-threatening emergency. She was given eight times the recommended dose of the drug used to induce early labour, a mistake that some experts say may have contributed to her death.

Mr Quate said “only a national inquiry” could uncover NHS failings across the country.

Lynsey Hamilton, Labour’s Holyrood candidate for Clydesdale who said that she lost her second child after symptoms of pre-eclampsia were missed, also attended the meeting alongside Labour’s health spokeswoman Jackie Baillie and Liberal Democrat MSP Willie Rennie.

It came just ahead of a Labour debate at Holyrood calling for a national inquiry into maternity and neonatal services, which Ms Baillie said “transcends party politics”.

Ms Keegan said babies who have died in hospitals “deserve the respect of a proper” independent investigation.

Her baby boy Mason died in 2023 due to sepsis and related feeding issues after medics failed to recognise how sick he was, incorrectly taking his temperature and holding incomplete records. Mason had hypothermia but equipment to warm him up was not properly sourced, a review found.

“If a baby died anywhere else the police would be investigating it, not work colleagues,” Ms Keegan said.

“I want accountability for the staff that were involved in his death.

“The things that happened should never, ever happen in healthcare.

“There seems to be this sort of no blame game in the NHS where nobody gets any blame ever.

“Sometimes people are to blame. If somebody is not doing their job correctly anywhere else there would be disciplinaries, there would be action.

“These people are letting our babies die and they are going to work the next day as if nothing happened.”

Ms Keegan said a lack of accountability has had “devastating consequences”. She said that despite years of issues “absolutely nothing has happened to these people that are responsible for our babies’ deaths”.

Mr Quate claimed that the way the system is set up in the NHS means staff are able to “jump over” the rules in place.

“They can ignore them without consequence, without accountability,” he said.

“They can look at it, accept that that’s what’s done, and nothing changes, nothing happens – but you get to walk home with somebody less in your family.

“It’s not acceptable.”

He claimed there were systemic issues and a culture of “impunity” within the nation’s health service “that have been operating for a long time without responsibility or consequence”.

He added: “These are identical stories and fatal outcomes but it shouldn’t take fatal outcomes to say it’s not good enough.”

Ms Hamilton agreed and said that similar incidents happening across different health boards showed the need for a nationwide inquiry, “because this isn’t just about Edinburgh or Glasgow or Ninewells or Wishaw – it’s about maternity and the culture that is now being brought about in maternity over years and years and years.”

During the Holyrood debate on Wednesday, Health Secretary Neil Gray said he had met one of the parents who attended Parliament that day and offered to meet with other families impacted.

The minister revealed last week that he “nearly lost” his wife during pregnancy after “inaccurate assessments” as he announced measures aimed at improving care for mothers-to be, including a maternity and neonatal taskforce to be set up which will listen to “women’s experiences of maternity services” and also “the voice of frontline midwives”.

He said that if the taskforce recommend a national review following health board inspections “the Government will take this forward”, adding “the Government is not shutting down the prospect of a review but the process already under way should conclude in that first instance”.

He told MSPs: “I put on record once again, at the outset, my deepest condolences to those that are here and my thanks to them for their bravery in speaking up about their personal experiences.

“I know how difficult that will have been but it helps to ensure that we can learn and make improvements so I am very, genuinely, very grateful to them for that and I would be happy to meet with them if that is possible.”

He said he wanted to reassure families that maternity and neonatal services are safe in Scotland.

NHS GGC said: “We extend our heartfelt condolences to Mason McLean’s family. The report recognises, despite staff documenting concerns raised about Mason, that there were some missed opportunities for care and we are very sorry for this. We value the importance of the voice of parents and carers, and include this in our assessment process.

“We also understand the investigation was lengthy and difficult. This complex review involved multiple departments, external input and a necessary wait for post-mortem results. We aimed to respond to every question and reflect the family’s feedback, including commissioning an additional external review.

“While staff documented concerns, a formal feeding assessment might have led to a more structured plan, though unlikely to have resulted in neonatal admission at that time. New infant feeding guidance has been created and is going through the appropriate approval process.

“We have also undertaken to action the recommendations identified in the SAER (significant adverse event review) and updated our neonatal guidance on many aspects of care including pathways, monitoring temperature, and observations.”

NHS Tayside said: “The tragic deaths of Ms Hunter and her baby Olivia were devastating for Mr Quate and we are so deeply sorry for his loss. We continue to extend our condolences to him and his extended family.

“NHS Tayside undertook a number of internal investigations and engaged in external reviews following the deaths to ensure all learning opportunities were taken by the organisation to deliver improvements.

“All recommendations identified in the reviews were fully accepted and, as a result, our systems and processes have been strengthened where required and improvements have been made to how we provide care.

“Our maternity services were inspected by Healthcare Improvement Scotland (HIS) as part of their routine safe delivery of care programme earlier this year.

“The focus of the inspection was different from the reviews following Ms Hunter and Olivia’s death.

“The HIS report identified areas for learning and improvement, and also highlighted where our teams were delivering sensitive, responsive and high-quality care.

“NHS Tayside is committed to providing safe, compassionate and high-quality services to women and families in our care.

“We also remain committed to continuously learning and improving so that we can offer the best possible support to every family we serve.”

NHS Lanarkshire has been approached for comment.