Urgent changes are needed to maternity triage in order to save lives.

A review of maternity services and previous reports into their safety has found inconsistencies in advice when expectant parents contact triage, and concerns that they are not properly listened to or their fears addressed.

And bereaved parents have appealed to Health Secretary Wes Streeting to act on the findings of the review and make the necessary changes to triage, which could save babies’ lives and prevent further tragedies occurring in hospitals across the country.

The paper, from the Sands and Tommy’s Policy Unit, also points to the fact there is no recognised national guidance for maternity triage, including an absence of a standardised approved system or reporting tool.

Analysis of information provided by different NHS Trusts also shows a disparity, with a variation in symptoms and language encouraging women to stay at home – which the paper says is without a clear evidence base.

“Women and birthing people must be provided with clear information on how and when to contact maternity services, and the response they should expect if they do,” the paper stated.

Problems with maternity triage have been highlighted on many occasions previously in separate hospitals - this research brings together reports from across the country to give a wider picture.

Katie Fowler and Robert Miller lost their daughter Abigail due to faults in maternity triage by the Maternity Assessment Unit (MAU) at the Royal Sussex County Hospital in January 2022.

Abigail died at only two days old, after staff failed to appreciate the severity of Katie’s condition despite four calls to the unit. Katie went into cardiac arrest on the journey to the hospital, and Abigail was delivered by emergency caesarean in a hospital waiting room.

"When I was in the early stages of labour with Abigail, my husband and I phoned our MAU four times. A subsequent HSIB (now MNSI) investigation into Abigail's death found that three out of four of the calls were mishandled and her inquest found that her life would have been ‘significantly prolonged’ if we'd been invited into hospital when we should have been,” says Katie.

“She died as a direct result of unclear guidance on how to manage telephone triage. Introducing national guidelines is such an easy fix and it would demonstrably save lives.

“I hope Wes Streeting will read this report and make the necessary changes immediately.”

Nisha Sharma, principal lawyer in our medical negligence team, who is acting in growing numbers of maternity cases, says change to triage is urgent and overdue.

“When expectant mothers contact their local maternity units with concerns, they will of course believe what they are told because they are being advised by professionals. But on too many occasions we know this has gone badly wrong, often with the most tragic of consequences,” says Nisha.

“It is truly shocking that there is no standardised guidance for maternity triage – this should be in place already in every maternity unit across the country, and the fact it isn’t is costing babies’ lives. This continues to happen, which is utterly devastating and avoidable.

“Improvements to triage is a step that must be implemented immediately, and we would echo calls for Wes Streeting to consider the findings of this review and take action to protect mothers and babies through improving maternity triage. This is a long overdue step and we consider it a priority for the new Health Secretary.”