Veil of silence over mother and baby deaths in Scottish hospitals

Calls for greater openness by health boards over baby deaths to helps parents work through the tragedy.

Around 500 babies have died in Scottish hospitals since 2019, but health authorities have managed to avoid any public scrutiny, we can reveal.

Our special investigation into maternity care standards has found dozens of mothers also lost their lives over the past five years, but health officials face no sanctions for refusing to say why.

Promises for “openness and transparency” were given by Healthcare Improvement Scotland (HIS) following the deaths of six babies at NHS Ayrshire and Arran’s Crosshouse Hospital almost a decade ago, and again after “sub-optimal care” was linked to five baby deaths at NHS Highland’s Caithness General Hospital around the same time.

HIS told health boards to share and learn from tragedies by publishing Significant Adverse Event Reviews (SAER), involving families and staff, in a bid to prevent further deaths and injuries.

But despite this, both NHS Ayrshire and Arran and NHS Highland are among health boards still refusing to publish SAER reports. Now bereaved parents say Scottish health boards have become even more evasive, leaving families battling for the truth.

College lecturer Fraser Morton, 47, whose son Lucas was one of six babies whose deaths were found to have been avoidable in the Ayrshire & Arran scandal, said: “All these years on, the betrayals continue while more lives are lost. Despite all the promises and millions spent on supposedly making the system more transparent, it’s now even harder for bereaved families to get to the truth.”

While NHS England is currently examining the deaths of over 2,500 babies, Scottish health officials refuse to publish vital reports to scrutinise maternity ward safety.

Fraser Morton, whose son Lucas was one of six babies whose deaths were found to have been avoidable in the Ayrshire & Arran baby death scandal.

Contacted by The Sunday Post last week, NHS Ayrshire & Arran insisted it was government quango HIS which ordered them to stop publishing SAERs.

Medical director Dr Crawford McGuffie said HIS “advised” that the health board stop published redacted SAERs as “these reports do not encourage shared learning and risk breaching patient and family confidentiality”. He said: “As a result, all SAER reports were removed from our website.”

It would not even reveal how many maternity related deaths occurred in the past five years, only saying 26 SAERs were instigated.

Scotland suffers 100 baby deaths every year, with dozens of mothers also losing their lives, while England has a thousand babies dying annually.

But while England has the coroner’s system to identify “red flags” over standards, campaigners warn Scotland’s secrecy and failure to publish reports prevents scrutiny.

Morton said: “If a hundred lives were being lost every year in an industrial setting there would be a public outcry. But because this is happening in hospitals, health officials are getting away with secrecy.

“Quite apart from the broken promises on transparency made to parents like us, the Harold Shipman inquiry highlighted the importance of openness to prevent recurrence. That’s why publishing SAERs is vital for public safety.

“Our health boards learned nothing from the tragedies of the past except how to make it even more difficult for families to find out the truth when things go wrong. Politicians cannot let this continue.

“Nothing can be more distressing than losing a child. Not being told why exacerbates the pain.

“With no proactive independent scrutiny, our health boards continue marking their own homework in while hundreds of lives are being lost with no explanation or accountability.”

HIS said: “The decision to share a SAER report publicly would be for individual NHS boards to decide. NHS boards currently notify us when commissioning such a review, but do not share the full report with us.”

Former nurse Rab Wilson, whose disclosures led to the Ayrshire & Arran baby deaths inquiry, said: “When mistakes cost lives, there is a duty of candour to inform the public.

“Without public access to SAERs, how can anyone even begin to spot red flags or make the vital links which could save lives.”

University Hospital Crosshouse, near Kilmarnock

Our probe showed NHS Highland, where five baby deaths were linked to “sub-optimal care” at Caithness General, refused to give the number of deaths of infants and mothers, admitting they don’t publish SAERs.

NHS Lothian recorded 300 “maternity related deaths” between 2019 and 2024 with Edinburgh Royal Infirmary recording 253, and St John’s in Livingston 47, and the deaths of less than five mothers every year apart from 2022. It refused to publish further details claiming data rules.

NHS Lanarkshire had 224 babies dying over the past five years. 77 were neonatal deaths and 147 were stillborn. Ten mothers also lost their lives. Despite 96 SAERs, none were published with NHS Lanarkshire citing data protection laws. NHS Tayside, which says less than five babies and five mothers have died in the last five years, also refuse to publish because “disclosing information about such events could lead to patients becoming identifiable and this would breach Data Protection Principles.”

NHS Grampian held 63 SAERs into neonatal deaths, stillbirths and mothers dying since 2019, but these have not been published. It reported 152 baby deaths, 61 neonatal and 91 stillbirths, saying less than five mothers died in each of the last five years, adding: “Not every death resulted in a report being produced.” The Scottish Government said: “We are currently meeting with leaders from all boards as part of a programme of work to improve SAERs, and HIS have recently published their updated national framework for the wider adverse event review process.”

NHS Lothian medical director Dr Tracey Gillies said: “Every death is a tragedy and, in line with national guidance, a full review is carried out to investigate unexpected or potentially avoidable events to understand and where possible implement actions to prevent similar incidents in the future.”

A series of failings

Scotland’s biggest baby death inquiry criticised NHS Ayrshire & Arran over six deaths.

They included the November 2015 death of Fraser Morton’s son, Lucas, who was born on a night when a third of staff were found to be absent.

A series of failings contributed to Lucas’s birth including the failure to monitor his heartbeat or to recognise his mother was suffering pre-eclampsia. Incidents examined in the inquiry dated back to 2008.

The inquiry found staff were unsure how to respond to SAER’s once they were initially reported and the maternity unit at Crosshouse Hospital were circumventing reporting procedures to make themselves look better.

HIS recommended the health board strengthen its adverse event management policy so it could be quickly and simply followed and improve engagement with bereaved families.

Dr Tracey Johnston, chairwoman of the independent review group, said: “There are clearly lessons to be learned from this review, not just for NHS Ayrshire &Arran but for Scotland as a whole.”

A second major inquiry into the deaths of five babies at Caithness Hospital from 2010 sparked major changes to the community unit which had no facilities for on-site neonatal paediatric support or adult intensive care, resulting in mothers being sent to Raigmore Hospital in Inverness.

Following criticism of the proposed changes, Dr Rod Harvey, NHS Highland’s medical director, said the midwife-led unit at Caithness General would be able to identify problems in pregnancies at an early stage, and that pregnant women who had to be transferred would be moved in a “calm and collected way”.