Exclusive:Scotland's Maternity Crisis: Bereaved families fear independent review will be 'waste of time'
Concerns over ‘forward-looking’ scope of review
Parents fighting for answers surrounding the deaths of babies in Scotland’s maternity services system have warned that an upcoming independent review is in danger of becoming an “absolute insult” and a “complete waste of time” as a result of its limited scope.
The maternal and child health expert, Professor Christine McCourt, will lead the review into improving maternity services across the country. Health secretary Angela Constance has promised it will “deliver real and tangible change” for women and their families.
But as part of Scotland on Sunday and The Scotsman’s week-long series, Scotland’s Maternity Crisis, families of babies and mothers who died as a result of failings in their care have condemned the remit of the long-awaited review. Over 4,300 people have signed a petition set up by one family calling for its approach to be broadened so as to scrutinise previous cases of death and avoidable harm.
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The review, announced by the Scottish government in June, will look at how maternity services can better meet women’s needs, including how care is provided in rural and island areas. It will also address the higher maternal mortality rates of black and Asian women, and review how health boards engage with their communities on maternity service decisions.
While the full scope and terms of reference have yet to be published by Prof McCourt, who leads the Centre for Maternal and Child Health Research at the City St George’s University of London, the nine month-long review’s stated principles specify it will be “forward-looking,” and note that it will be “informed by the experiences of women, families and staff.”
However, bereaved families said they were deeply concerned that such a definition will exclude any focus on historical clinical practice, systemic failures, and previous tragedies.
An England-wide independent national maternity and neonatal investigation by Baroness Amos, which published its final report earlier this summer, conducted reviews of 12 NHS trusts, and heard from more than 450 families and over 9,000 staff through surveys, site visits and one-to-one discussions.
One family who have called for an overhaul of the Scottish review’s remit is Julie Keegan and Angus McLean. Their three day-old son, Mason, died after a series of failings in his care under NHS Greater Glasgow and Clyde health board in January 2023.
As well as continuing to fight for answers as to the circumstances behind their son’s death, Ms Keegan and Mr McLean have launched a campaign to drive change in Scotland’s maternity care system.
The couple said that while they welcomed the independent review, they “fundamentally disagreed” with the decision for it to take only a forward-looking approach, and emphasised that families should have a “seat at the table.”
“They don’t want to look at anything in the past,” Ms Keegan told Scotland on Sunday. “They want to just wipe the slate clean and look to the future. But this has been going on for years, and it’s a toxic culture that needs to be investigated to stop things like this from happening.
“It feels like it’s going to be a complete waste of time if it’s just going to be a forward looking model, it’s an absolute insult. We fought really hard for this independent review, and already, it just feels like it’s going to be nothing like the change that we need.
“We want a proper inquiry that is going to investigate the failings of the past. Ultimately, we don’t want a review that’s just looking to the future. We want to understand how all the things in the past were allowed to happen and that is how we will get positive change. The families want to be part of this review, we can’t be pushed out.”
The couple has already met with Ms Constance, but described the encounter as “disappointing.” Mr McLean said: “There was a lot said, but not really any action.”
As part of their campaign, Ms Keegan and Mr McLean want to ensure the review is informed by previous cases of avoidable harm and death, and that it identifies and addresses “recurring patterns and systemic failures.”
They also want to see a change to health board reviews so that practitioners are not investigating the decisions, action, and possible failures of their colleagues, with “robust scrutiny and accountability” whenever risks are taken, or established procedures are not taken.
“The government has promised change before. Families are still being failed,” they stressed. “This review cannot be another broken promise. It has to deliver real change.”
Lori-Mark Quate, whose wife, Jacqui Hunter, died giving birth to their stillborn daughter, Olivia, said the healthcare system was “not interested in learning lessons,” and stressed the need for existing standards to be strictly followed and monitored.
Jacqui, 39, suffered a cardiac arrest and died from an amniotic fluid embolism in May 2020 at Ninewells Hospital in Dundee. Mr Quate only discovered afterwards that his wife had been administered eight times the recommended dose of Misoprostol, the drug used to bring on labour.
A fatal accident inquiry concluded it was possible, but not probable, that her death could have been prevented if she had been given the correct dose. An NHS Tayside review panel said the incorrect dose must be considered as a “major contributing factor” in the AFE and death.
Mr Quate said: “A major bone of contention for me is the fact there needs to be enforcement of standards and protocols, and there needs to be legal, punitive repercussions if the legal duty of candour is not followed. It either exists and means something, or it’s absolutely worthless, and right now, it’s sadly worthless.
“I’ve told the health secretary my concerns about the review’s scope, because the problems lie in dirty, nasty little corners, and there’s a willingness to pretend they don’t exist, hide them, and keep them from scrutiny.
“It is these corners where the failings are and this culture resides. If the review is not willing to roll sleeves up and strongarm change, it will never be changed.”
Ms Constance said: “No parent should ever have to go through what Mason’s family experienced and I am deeply sorry for their loss. One of my first acts as health secretary was to establish the independent review of maternity services and I am fully committed to ensuring lasting improvements are made to maternity care in Scotland.
“I was grateful to meet with Julie and Angus three weeks ago to discuss their experience and I agreed to look closely at a number of their concerns. I was also grateful to meet with Lori-Mark Quate and his mother last week to hear more about the passing of his wife Jacqui and baby daughter Olivia.
“It is very important to me that the review hears from women and families who have direct experiences of maternity care and we will ensure details of those who wish to engage are passed to the review team.”
She added: “While it will be for Professor McCourt as the independent chair of the review to determine how the review is conducted, I believe a forward-looking and improvement-focused independent review will identify the systemic changes needed to strengthen services and achieve better outcomes for women, babies and families.
“Meantime, Healthcare Improvement Scotland are continuing their inspections of maternity acute units which are shining a light on maternity services, as they should, and are providing vital insight for boards on where their services are performing well and where they need to improve to ensure quality and safety of services.”
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