A recent surge in stillbirths, along with a maternal death linked to Gloucestershire Hospitals NHS Foundation Trust, has prompted comprehensive investigations to ensure patient safety and care quality. Between September and December 2024, nine stillbirths were recorded within Gloucestershire, according to the latest trust data. Additionally, one maternal death occurred out of county but involved a labour managed by the trust.
The figures and ongoing review were presented at the trust board meeting on May 8. Each stillbirth case has undergone a rigorous multi-professional governance process. Six cases are currently subject to patient safety incident investigations, while one is being reviewed by the maternity and neonatal safety investigations team. This scrutiny has already revealed immediate areas for improvement.
Key findings emphasize reducing unnecessary variation in antenatal midwifery care, enhancing access to ultrasound services, and improving language interpretation support for non-English-speaking women. While stillbirths are rare, the trust expects about 15 cases annually given the size of its maternity unit. Monthly figures naturally fluctuate, making it difficult to determine the statistical significance of recent increases. Regardless, the trust maintains heightened surveillance due to the profound impact of each loss.
READ MORE: The Repair Shop Star Will Kirk: From Early TV Roles to Personal Heartbreak
READ MORE: Newark Park’s Spectacular Allium Bloom Illuminates Historic Gardens
Matt Holdaway, Chief Nurse and Director of Quality, reassured the board that all stillbirths were reviewed thoroughly through local governance frameworks and a patient safety review panel. He highlighted that investigations continue, with one case referred to the neonatal safety investigation team.
“There was also one maternal death reported to MBRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries),” Holdaway added. “Although the death occurred outside our area, the labour was under our care. No neonatal deaths have been recorded during this period.”
Trust chairman Deborah Evans acknowledged the difficulty in pinpointing causes for many stillbirths. “It’s reassuring that we are conducting a detailed review of antenatal care practices and addressing variations,” she said. “While this is not an exact science, it’s crucial to identify best practices and uncover areas for improvement.”
The investigations reflect the trust’s commitment to learning from every case and enhancing maternity services to prevent future tragedies.