At least 55 babies who died at NHS trust ‘may have survived’ with better care, review finds

At least 55 babies who died at University Hospitals Sussex NHS Foundation Trust could have survived with improved care, a new review has revealed.

Last June, Health Secretary Wes Streeting initiated an independent investigation into maternity services at the trust, an inquiry that has since expanded to include 15 families.

Discussions are currently ongoing between these families and the government regarding who will lead this critical investigation.

The trust’s own internal review, conducted between 2019 and 2023, examined maternity deaths and concluded that a different outcome might have been possible for 55 infants.

Freedom of Information (FOI) data, obtained by the group Truth for Our Babies – established by bereaved parents – indicates that the trust carried out 227 internal hospital reviews into maternity deaths during this period.

Of these, at least 55 cases were assigned grades of C or D, signifying that alternative care “may” or was “likely” to have altered the outcome.

Among the affected families is Robert Miller, whose daughter, Abigail Fowler Miller, tragically died just two days after her birth at the Royal Sussex County Hospital in Brighton in January 2022.

An inquest later determined that Abigail would likely have survived had her mother, Katie Fowler, received medical treatment sooner. Ms Fowler also suffered a cardiac arrest during the ordeal.

Mr Miller is one of several parents advocating for senior midwife and investigator Donna Ockenden to lead the independent inquiry into the events in Sussex.

He told the Press Association that Ms Ockenden is “someone that families across the UK trust,” adding: “It’s about our trauma and our harm and not being re-traumatised unnecessarily.

“It’s difficult for us to accept someone who’s never done this before and is learning on the job – that’s the bottom line. We’re scared of being re-traumatised and having more harm done to us through this process by someone who perhaps has never done it before on this scale.”

Mr Miller also expressed concerns that a current national maternity review, commissioned by the government and led by Baroness Amos, does not go far enough.

“We’re still of the opinion that a judge-led public inquiry is really needed to hold people to account, to really scrutinise and be able to compel people to give evidence,” he stated.

Regarding the situation in Sussex, he lamented: “We’re not seeing improvements quickly enough.”

A Care Quality Commission (CQC) report in December rated maternity care at the Royal Sussex County Hospital as requiring improvement, which Mr Miller noted was “only up one step from inadequate four years ago.”

He concluded: “To us, improvement is not happening quick enough to save babies’ lives.”

A Department of Health and Social Care spokeswoman affirmed: “Every family who has lost a baby deserves answers, and we are determined to ensure they get them.

“We are actively working with families in Sussex to appoint a chair and agree terms of reference for this vital review. No one should experience substandard maternity care, and this government will not rest until women, babies and families get the care they need, in Sussex and beyond.

“Bereaved families will remain at the heart of Baroness Amos’ national investigation every step of the way. The opening of a call for evidence last month provides an important opportunity for women and families affected to share their experience.”

Dr Andy Heeps, chief executive of University Hospitals Sussex NHS Foundation Trust, offered a heartfelt apology: “No words can truly express the heartbreak of losing a child.

“To every family who has experienced this unimaginable loss, I want to say directly: we did not always get things right. As chief executive, I take responsibility for that, and I am deeply sorry for the pain and distress you experienced while under our care.”

He added: “Our purpose is simple: to provide the safest possible maternity care. To do that, we must listen to women and families, learn from moments where care has fallen short, and support our staff to make meaningful improvements.”

Dr Heeps detailed the trust’s actions, including a thorough investigation into neonatal deaths in 2021–2022, which led to immediate changes.

He highlighted several improvements: “We have recruited 40 additional midwives across our four maternity units, bringing us to full staffing. We have increased theatre capacity for planned Caesarean births.

“And we have introduced a dedicated telephone triage service, staffed by highly experienced midwives whose sole focus is making safe, timely decisions about when women should come into hospital.”

He acknowledged that while these changes “are making a difference,” there is “always more to do” and welcomed the various investigations.

The trust reported that its perinatal mortality rate had fallen to 2.19 per 1,000 births as of last October, down from a previous rate of around three per 1,000. Over the past three years, the trust states its rate has remained consistently below the national average.

In Mr Miller’s case, his wife, Ms Fowler, experienced a “straightforward” pregnancy.

She went into labour at home and contacted the hospital around 10am on January 21, 2022. After two more calls due to bleeding, a fourth call reported her feeling faint and out of breath.

While travelling to the hospital by taxi, Ms Fowler suffered a cardiac arrest caused by a uterine rupture, requiring 20 minutes of resuscitation.

Abigail was delivered via Caesarean section, but it took 40 minutes to resuscitate and stabilise her.

Ms Fowler was placed in an induced coma, waking on January 23 to meet her daughter, who died later that day.

An inquest concluded that medical intervention should have occurred sooner, with a Healthcare Safety Investigation Branch report also issuing safety recommendations.