No matter how prepared or well-informed a woman may feel, pregnancy and childbirth are among the most vulnerable moments of her life. When she walks into a maternity ward, she places her own safety – and her baby’s – in the hands of medical professionals. In Britain today, that trust is being betrayed.
According to the Care Quality Commission (CQC), almost half of England’s maternity units are rated as requiring improvement or inadequate. Over the past decade, three major investigations have exposed catastrophic failures in individual hospital trusts. A fourth, covering 2,425 families in Nottingham, is underway; a fifth, examining Leeds, was announced in October. “This is a national scandal,” Health Secretary Wes Streeting admitted in June, launching a nationwide maternity and neonatal investigation. “Too many children have been dying.”
In September, Streeting confirmed that 14 maternity trusts would face a rapid review, led by Labour peer Valerie Amos. Among them was Oxford University Hospitals NHS Foundation Trust (OUH) – a name that came as no surprise to the New Statesman and Channel 4 News, who had already spent four months investigating its record. They spoke to 24 women whose stories stretch from 2009 to this summer: stories of stillbirths, neonatal deaths, lifelong injuries and lasting trauma – and of a culture that punished women for speaking out.
“She Was Perfect – Just Dead.”
One of those mothers is Alice Topping. Her daughter, Smokey, was stillborn at Oxford’s John Radcliffe Hospital in September 2023. Alice’s pregnancy had been classified as high-risk, yet she says her warnings were ignored and vital scans were denied. When she begged for help, she says she called the hospital 44 times in one day.
An ultrasound at 20 weeks had shown restricted blood flow between mother and baby, and late in pregnancy she developed gestational hypertension – both risk factors for stillbirth. Yet Alice’s request for an earlier induction was dismissed. “No one explained to me how dangerous it was to wait,” she said.
At the time, OUH policy advised induction between 40 and 41 weeks, even for high-risk women. Four independent obstetricians told investigators that, in similar circumstances, they would have induced by 39 weeks.
When Smokey died, OUH’s stillbirth rate was the worst in the UK. It had been classed as “red” or “amber” on official perinatal mortality data every year since 2017.
Alice later discovered that her hospital had denied her scan requests under a restrictive internal policy known as OxGrip – a 36-week ultrasound programme designed to reduce stillbirths while “making best use of resources.” OUH’s own obstetricians had warned in presentations that “at least half” of scan requests were rejected to make the system viable.
National guidance from NICE and the Royal College of Obstetricians and Gynaecologists (RCOG) recommends regular growth scans for high-risk pregnancies until delivery. Smokey’s mother went more than five weeks without one. The Maternity and Newborn Safety Investigation programme concluded that OUH’s “growth surveillance guidelines are not in line with national guidance.”
Despite this, OUH’s own review found “no issues identified with the care provided.” Its report, Alice says, appeared to blame her for not trusting clinical advice. “They left Smokey to suffocate inside me and then blamed me for her death.”
The Health Secretary has now asked NHS England to investigate the OxGrip system “immediately” – how it is monitored, whether it improves safety, and whether it deprives high-risk women of essential scans.
Denied Choice, Denied Dignity
OUH’s problems run deeper than one failed policy. Until 2021, the trust had an explicit ban on maternal-request Caesarean sections – in direct breach of NICE guidelines that had been in place for a decade.
Some women were forced to travel miles to other hospitals. Others were traumatised by being coerced into “natural” births. “I still can’t celebrate my son’s birthday,” one woman said. “Our bond feels weak.”
The rigid policy reflected a wider NHS obsession with “normal births,” reinforced by national targets to reduce C-sections. Those targets were scrapped in 2022, but their legacy persists.
Gothami Hettiarachchi, who had a damaged heart valve, was told by doctors in Sri Lanka that a vaginal birth could be dangerous. Yet when she became pregnant in Oxford in 2017, OUH staff repeatedly pushed her toward a natural birth. “At 38 weeks, they told me, ‘We won’t do it here,’” she recalled. “I thought I’d die.” After four days in labour, she required an emergency C-section. The emotional fallout, she said, destroyed her ability to bond with her baby.
“Doctors Know Best”
Solicitor Laura Cook, who has represented families in negligence cases against OUH for 25 years, says the trust operates with a “paternalistic” culture. “It’s consultant-driven rather than patient-led,” she explained. “Women aren’t given full information. The attitude is: ‘We know best.’”
The New Statesman uncovered case after case supporting her view.
In 2011, 17-year-old Emma Cox lost her twin daughters, Hope and Lilly, after what she calls a series of catastrophic decisions at John Radcliffe Hospital. When one twin was delivered prematurely and pronounced dead, a midwife later returned with the baby, explaining: “She can’t go to the mortuary – she’s breathing.”
Emma begged for her daughter to be taken to the neonatal unit. Staff refused. Lilly survived for 24 hours without intervention. Emma later learned that hospital officials admitted the baby “might have survived” but with disabilities. “That was not their choice to make,” she said.
Years later, she discovered she was not alone. Hundreds of mothers began sharing similar stories in a Facebook group, Families Failed by OUH Maternity Services, founded by Rebecca Matthews in 2023. Their accounts described a lack of compassion, denial of choice, and a dismissive attitude toward women’s fears.
By late 2024, 660 families had come forward – more than those involved in Nottingham’s ongoing maternity inquiry.
Lessons Unlearned
Exclusive figures from the Maternity and Newborn Safety Investigation programme show OUH repeatedly received the same safety recommendations year after year – including urgent warnings to improve baby heart-rate monitoring after multiple deaths and severe injuries.
Even now, the trust’s own board papers list avoidable deaths due to “unclear policies” around scans for mothers with hypertension.
Midwives who spoke to investigators described burnout, fear, and “compassion fatigue.” One said: “When we don’t feel safe, women feel that too.”
Streeting now faces a question that no inquiry alone can solve. “There’s a cultural problem across the NHS,” he told reporters, “where protecting reputations comes before protecting patients.”
For mothers like Alice, Emma, and Gothami, that truth has already come too late.
