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Lessons to be learnt from tragic maternity cases, says Clarke Willmott

Kerry Fifield, partner and team leader of our Bristol clinical negligence team, recently represented a mother who lost her baby due to failings in a Cheltenham maternity unit. She says that the same issues are arising “time and time again” in NHS Trusts around the country.


Jasper White died in June 2019, 11 hours after being born at the Cheltenham Birth Centre. His health had deteriorated immediately after his birth and he needed to be transferred to Gloucester Hospital by ambulance, but there was a 50-minute delay before the transfer to the neonatal unit took place.

A report by the Healthcare Safety Investigation Branch (HSIB) identified a number of failings in Jasper’s care and a significant delay in arranging the hospital transfer.

It concluded that there was no ‘helicopter view’, resulting in a 25-minute delay from when Jasper deteriorated to when the decision was made to transfer him for review. It then took a further 19 minutes to call the ambulance. The total time from the decision being made to Jasper’s arrival at the hospital was just under one and a half hours.

More cases of negligence by Gloucestershire Hospitals NHS Foundation Trust

Jasper’s death was followed in 2020 by that of Margot Bowtell, who died in the same maternity unit, part of Gloucestershire Hospitals NHS Foundation Trust. Margot was born in the same unit not breathing and was transferred to hospital in Bristol three days later, where she died. A report concluded that the outcome could have changed had Margot been transferred sooner.

The two cases were the subject of a BBC Panorama investigation which screened on Monday evening, highlighting concerns around staffing issued raised by midwifery staff at the unit.

Two other health Trusts have also been the subject of damning reports into maternity care in recent years.

A report identified the unnecessary deaths of one mother and 11 babies in the maternity unit at Furness Hospital in Barrow, part of Morecambe Bay NHS Foundation Trust, between 2004 and 2013.

A separate report concluded that 300 babies were left either dead or brain damaged due to inadequate care at Shrewsbury and Telford NHS Trust from 2000-2019. At least 12 mothers died while giving birth in the Trust’s hospitals.


Gloucestershire Hospitals NHS Foundation Trust was not prepared to formally accept that the death could have been prevented, which was contrary to the independent evidence we obtained,” says Kerry, who represented Jasper’s mother Laura White.

“Despite the denial, the Trust did wish to explore settlement of the case. I find it shocking and frustrating that when concerns are being raised internally that, naively perhaps, those concerns are not taken seriously and acted upon to prevent this happening in the future.

“Having acted for families in similar situations over the last 20 years, we are seeing the same issues with arise time and time again with devastating consequences.” said Kerry.

Baby loss frequently asked questions

Get answers to your frequently asked questions about baby loss and clinical negligence by watching our interview with Vanessa Harris, Senior Associate in our clinical negligence team. In the video, Vanessa talks about when to instruct a lawyer and where families can go for support.

Speak to an expert

If you or your family have been affected by the issues raised or require advice in respect of maternal care or birth injuries, please contact Clarke Willmott’s clinical negligence team on 0800 316 8892.

Your key contact

Kerry Fifield

Partner and Clinical Negligence Team Manager

Kerry’s primary focus is the needs of the client and their family when pursuing a claim, taking into account that each client is an individual with specific requirements who needs to be supported in addition to the legal investigation.
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