Investigation Highlights Gaps in Bradford Maternity Care
Lauren Caulfield was under the care of Bradford Teaching Hospitals NHS Foundation Trust during her pregnancy.
An investigation into maternity services has been urged to extend "much further" by a Bradford woman whose daughter was stillborn due to shortcomings in her care. The National Maternity and Neonatal Investigation identified a "clear gap" between the intentions of staff at Bradford's maternity services and the actual experiences of families.
The review, led by Baroness Amos, concluded that maternity services across the country require "urgent" reform and are currently inadequate to provide high-quality care.
Mel Pickup, chief executive of Bradford Teaching Hospitals NHS Foundation Trust (BTHFT), issued an apology to the "women whom we have let down" and acknowledged the "lasting trauma and harm" caused. She also noted that neonatal services at the trust recently received an Outstanding rating from the Care Quality Commission (CQC), while maternity services were rated Good.
Among 12 NHS trusts examined in the investigation, women receiving care at BTHFT reported feeling they were not "believed, listened to or taken seriously".
Personal Experiences and Calls for Inquiry
During her pregnancy, Lauren Caulfield was cared for by both Leeds Teaching Hospitals NHS Trust and BTHFT. Her daughter Grace died shortly before birth in 2022.
"It's a known fact that women and families are not listened to in maternity services, but I honestly don't feel women or families have been listened to as part of this report.
I've been involved in it since the beginning, there's been many families that have put to Baroness Amos and her team what needs to happen in maternity to make it more safe, make it more equitable, and ensure that people don't harm or experience harm and that's been completely ignored."
Caulfield, currently a student midwife, emphasized the need for a statutory public inquiry, citing a "systemic problem".
"Most of the staff I work with have been wanting to do the best they can but they're working in systems that do not support them - whether that's not enough staff, excessive work hours or not enough patient care, not enough time to provide the care that people want to," she said.
Report Findings on Staffing and Environment
Baroness Amos' report detailed issues at Bradford Royal Infirmary including busy wards, stretched staffing, heavy administrative workloads, and digital systems that were "difficult to navigate".
Families reported feeling that the hospital service was "under pressure," which negatively impacted the care they received.
The report stated:
"Staff spend significant time looking for information or completing tasks that take them away from families.
Families noticed this too, describing staff being drawn to computers, when what they needed was reassurance and encouragement."
Some women who spoke to investigators felt patronized and believed their symptoms were dismissed. They described feeling "coerced rather than supported," with some stating they were told they "could not go home or make feeding decisions unless they complied with staff expectations."
The report also raised concerns about communication and language barriers, with some mothers receiving conflicting advice from staff members. Additionally, the age and layout of the Bradford Royal Infirmary site were cited as factors causing delays, stress, and additional pressure.
The complaints process at the Bradford trust was described as difficult to understand and slow, with families feeling met with "silence and a lack of explanation," according to the report.
The report noted that the women's experiences spanned various time periods, indicating that some issues, such as estate conditions or working methods, may have since changed.
Patient Experiences Highlight Care Deficiencies
Bethany Sugden shared her experience of giving birth at Bradford Royal Infirmary, where she had her third child via emergency C-section.
"I received poor care throughout the birth - and only one midwife was caring through that whole time.
During the C-section, no one talked us through a single thing. I didn't even know the baby had been born," she said.
"Even right down to asking for a shower for hours and hours, and a student midwife said, 'yeah, you go, I'll watch the baby.'
A couple of minutes into the shower on the ward, I could hear the baby absolutely screaming and I was thinking, she's all right, she's with somebody.
I wasn't in the shower long, but when I got out, the baby was on her own. She was just left on her own to scream."
Sugden also reported that upon discharge, the trust failed to send correct information to community midwives. When a midwife visited two days later, the newborn was found to have jaundice.
"She was treated, but it was missed because of how exhausted I was and how exhausted everybody was by the whole ordeal," Sugden said.
Beth Troy recounted her traumatic experience during labour at Bradford Royal Infirmary three years ago, when she suffered an acute kidney injury that was repeatedly ignored.
"My cries for help and complaints of pain had been repeatedly ignored.
My kidney infection had been missed because a member of staff had recorded it on a piece of template paper and that was 'shoved in my file - no one ever looked at it ever again,'" she said.
"I was begging for pain relief – explaining that I didn't think my symptoms were right, that I was having really bad pain with my kidneys and I wasn't being listened to."
"I was put in a side room. It was a room full of piles of chairs, about eight birthing balls and an old sofa. No medical equipment, no bed. I was in there for about four hours."
When she gave birth via emergency C-section, her son arrived in just four minutes, leaving staff insufficient time to put up a privacy screen.
Troy said she later received a report from the trust explaining the errors and apologizing for the inadequate care.
"It was really scary to get that report afterwards and things could have gone so much worse than they did, and what did happen was really traumatising," she said.
Troy and her husband have since decided not to have more children due to the experience.
Trust Response to Report Findings
In response to Baroness Amos' report, Mel Pickup stated:
"Every year, thousands of women give birth under our care, and we want each and every one of those women and their families to receive excellent care and have a positive experience with us.
In most cases this happens, but we know that it does not happen for everyone – and that is not good enough. For those women whom we have let down, I am sorry.
I recognise the lasting trauma and harm experienced both by Bradford families sharing their experiences of care, and the many families contributing to the wider investigation."
Pickup acknowledged the courage required to share experiences and expressed the trust's willingness to listen further to local families to improve care.
"Dedicated and passionate colleagues have worked hard to improve the trust's maternity and neonatal services.
Over the past 24 months this has resulted in an 'Outstanding' rating for our neonatal services and a 'Good' rating for our maternity services from the Care Quality Commission. We know we can do more and we will do so," she said.
"I hope that the involvement of families, colleagues and our trust in the national investigation helps bring about lasting change across all maternity and neonatal services.
We will continue to work with our colleagues and partners to provide the best possible care for our families and create a service that our colleagues are proud to work in. That should be the lasting legacy for the families who have so bravely taken part in the investigation."
Additional Information
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