Maternity services in Glasgow under 'dangerous' pressure

A further 168 resulted in major injury or illness requiring surgical intervention, a return to theatre or admission to intensive or high dependency care, and 58 resulted in moderate injury or illness.

Significant adverse events are the most serious patient safety incidents in the NHS — those that have caused, or could have caused, death, permanent harm or major injury to a patient.

In maternity and neonatal services, they include stillbirths, babies suffering severe brain injuries, and cases requiring emergency intensive care.

Each incident is supposed to trigger a formal significant adverse event review — an investigation to determine whether the clinical care provided was appropriate and to identify any underlying systemic failures.

Where failings are found, the review should produce an action plan to prevent the same thing from happening again.

Not every review concludes that error was involved; in some cases, the care provided is found to have been appropriate and the outcome ultimately unavoidable.

The Queen Elizabeth University Hospital, Glasgow (Image: Colin Mearns)

The majority of incidents — 299 — occurred at the Princess Royal Maternity in Glasgow, with 235 at the Queen Elizabeth University Hospital, 128 at the Royal Alexandra Hospital in Paisley and 67 at the Royal Hospital for Children.

Healthcare Improvement Scotland (HIS) national framework guidelines state that an SAER should be commissioned within 10 working days of an incident, and the review should be completed within 90 working days.

However, in NHSGGC only 147 were commissioned from the 736 cases. Those that were completed took an average of 222 working days to conclude. Some reviews are still open.

A “themed analysis” of the action plans generated by those reviews, prepared by the board using Microsoft's AI Co‑pilot software, identified recurring failures across nine categories.

A lack of proper training was a recurring problem, specifically around how staff were using and interpreting CTG machines — the equipment that tracks a baby's heartbeat and the mother's contractions during labour.

There was also a need to improve staff understanding of specific conditions including diabetes and sepsis.

Documentation and record‑keeping failures were also heavily recurring, with incomplete or unclear records and a lack of documented ownership of care repeatedly implicated in the events.

The board's own analysis concluded that “documentation quality is repeatedly implicated in system failures, affecting patient safety, continuity and medico‑legal clarity.”

There was also identified variability in clinical vigilance, escalation thresholds, and senior involvement.

Communication breakdowns — particularly between maternity, neonatal, intensive care and Scottish Ambulance Service teams — were identified as a frequent contributory factor, with problems noted around handover failures, language barriers for patients and a reliance on outdated paging systems.

Julie Keegan knows what those failures look like in practice. Her son, Mason Scott McLean, died at the QEUH in 2023 after a litany of mistakes by medics.

She said the significant adverse event review into Mason's death contained factual and medical inaccuracies.

“It was just saying all policies had been followed when all policies had not been followed. If the policies had been followed, Mason would still be alive today,” Ms Keegan told The Herald.

Mason Scott McLean was born on March 29, 2023. He died when he was three days old. (Image: Julie Keegan)

Ms Keegan, an ICU nurse, and Mason’s dad, Angus, believe SAERs should be published as a matter of course.

“Why are we hiding all these absolute horrendous things that happen? If they were public and people could see how bad things actually are, how terrible it is for families, then there could actually be change.”

An unannounced inspection of the QEUH maternity unit, published last week by Healthcare Improvement Scotland, resulted in 26 requirements — formal instructions to meet national standards — and ended with the inspectorate formally escalating its concerns to the Scottish Government in March.

Inspectors found staff describing barriers to submitting incident reports and said they were being told they were filing too many.

Reports had been closed before the outcome for the woman or baby was known, including cases where the baby's condition post‑birth had not been established.

The inspectorate found 34 outstanding actions from completed adverse event reviews — some between six months and two years overdue — in a picture consistent with the board's own FOI figures showing an average review time of more than 10 months.

Women faced delays of up to 190 hours for the induction of labour due to staffing and capacity pressures.

In a six‑month period, at least 128 women experienced delays accessing the labour ward, one‑to‑one midwifery care, or the induction process.

The initial triage assessment was completed within the required 15‑minute target for only 61.6% of attendees, against an expected standard of 80%.

Staff described working conditions as “unsafe” or “dangerous” in incident reports. Senior charge midwives told inspectors their professional risk assessments were routinely downgraded by senior managers at cross‑site safety huddles without explanation.

Many staff said they were regularly unable to take statutory rest breaks — a situation inspectors said had become “an accepted practice within the service”.

Mandatory training compliance among midwifery staff ranged between 39% and 53%.

Only 37% of obstetric staff had completed online CTG training.

The unit, which handles around 4,800 births a year and is Scotland's only facility for fetal medicine surgery, also failed on basic safety checks.

Inspectors found emergency trolleys with expired medication, fire doors wedged open, mould in shower trays, leaking windows and hazardous cleaning products left unsecured in areas accessible to patients and the public.

Around 600 women who requested a face‑to‑face interpreter were not provided with one in 2025 — a failing that had appeared repeatedly in the board's own adverse event reviews and clinical safety meetings.

The health board has the highest proportion of pregnant women from ethnic minorities in Scotland, at 30%

Scottish Labour deputy leader Jackie Baillie said: “These shocking figures show maternity and neonatal services in Glasgow are under a dangerous amount of pressure.

“Where things do go wrong, it is crucial that families get the answers they deserve. The health board and the SNP Government must explain why so many of these cases don’t result in any review and why reviews take so long to conclude.

“It is crucial that services are learning from the mistakes made and improving failures such as communication so families can have confidence in these crucial services.

“The SNP must act with urgency to improve maternity and neonatal care in Glasgow and across Scotland, starting by delivering the comprehensive review promised last year.”

A spokesperson for NHSGGC said: “We would like to apologise to patients and families who may be affected by these delays.

"We are committed to being open, honest and supportive towards those affected by adverse events and aim to ensure consistent, high-quality and timely reviews with shared learning.

"Following a review, we have developed a new policy in line with the HIS Adverse Event Framework, which allows us to prioritise investigations into the most complex cases and to respond more efficiently to incidents.

"In line with the Framework, NHSGGC notifies category one events and continuously evaluates its approach to managing adverse events."