A Tragic Reminder: Lessons Still Not Learned in Maternity Care

The arrival of a newborn baby is one of life's most joyful moments. But when a baby becomes seriously unwell, that joy can quickly turn to fear—and, tragically for some families, heartbreak. For any parent, the loss of a child is unimaginable. And when that loss stems from preventable failings, the grief is only compounded.

It was a devastating reality for one family whose baby girl died at just one week old in November 2019. Despite the prior failings highlighted in the Kirkup Report 2015, which found serious shortcomings in maternity care at University Hospitals of Morecambe Bay NHS Foundation Trust, the necessary lessons were not fully learned.

A 19-day inquest concluded in March 2025, with Coroner Mr James Adeley ruling that there were "multiple missed opportunities" in the care the baby received during birth at the Royal Lancaster Infirmary. Midwives failed to act on warning signs, including a falling heartbeat, leading to the baby suffering hypoxic brain damage caused by oxygen deprivation.

Mr Adeley's findings were damning. Despite a decade having passed since the Kirkup Report—which concluded that the deaths of one mother and 11 babies could have been prevented with proper clinical care—similar issues were still evident in 2019. He issued a Prevention of Future Deaths report to the Department of Health and Social Care and the Trust, highlighting ongoing concerns around patient safety and transparency.

In his conclusion, Mr Adeley criticized the Trust's internal investigations as "unskilled, superficial, and brief," leaving the grieving family without the needed answers. While some improvements were noted, significant concerns remain—particularly around the Trust's ability to identify, engage with, and address serious safety and safeguarding issues.

The report has also been shared with NHS England, NHS Lancashire, and the South Cumbria Integrated Care Board. Both acknowledged the identified failings and stated that improvements were made during the inquest.

This case is a sobering reminder that patient safety must always come first—and that acknowledging past mistakes is only the first step. Real, lasting change requires action, accountability, and a steadfast commitment to learning from tragedy.

If you or a loved one has suffered an injury due to the negligence of a medical or health professional during childbirth, then we can help you pursue a medical negligence claim. Don't hesitate to contact Graystons for advice and support at 0151 645 0055 or by email at enquiries@graystons.co.uk.