Women felt their worries were minimised or even blamed on them at Queen’s Hospital’s “factory-like” maternity unit, an investigation has found.
Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT)—which runs the hospital in Romford —was among 12 NHS trusts visited as part of the National Maternity and Neonatal Investigation, led by Baroness Amos.
While investigators noted improvements to maternity services at the trust, they found a “clear difference” between what the executive team believe is delivered and the experience of families themselves.
Women told the investigation they were left feeling unsafe and unheard, describing distressing pregnancies and labours where early warning signs were missed or dismissed until emergencies unfolded.
Families repeatedly voiced concerns about pain, reduced baby movements, or unusual symptoms only to be dismissed or reassured without clear explanation.
One woman said: “I suffer with anxiety and that was used against me the whole time that I was there.
"‘You’re so anxious, you’re very anxious.’ I said: ‘Yeah, I am anxious because something’s wrong, the baby’s not moving’… ‘You’re anxious. This anxiety needs to stop because this is what’s not good for your baby.’”
In response to the report, chief nurse Nic Kane said: “We’re pleased we were able to show Baroness Amos and her team the improvements we’ve made to our maternity services, which led the Care Quality Commission to rate them as 'good' overall last year.
“Her report on our trust highlights that these positive changes have come too late for the families who have experienced harm or bereavement.
"We are truly sorry that their experiences have had a lasting, harmful impact on them and their loved ones.
“We know we must do more. We will continue to improve how we communicate with parents, respond to complaints, and ensure the maternity care we provide is the best it can be.”
'Chaotic and factory-like'
Investigators did not limit how far back families could talk about their care at Queen’s, so some of the problems they described may since have improved or deteriorated.
“However, there is consistency in the issues raised and the themes which have emerged remain important in understanding how families felt and what mattered most to them at the time,” the report stated.
Several women said the pressure on the unit made their experience feel "chaotic" and "factory-like", with staff focused on moving people through rather than showing compassion.
Some mothers described being in active labour without a bed or adequate pain relief, and later feeling "out of sight, out of mind" on postnatal wards once their baby had been delivered and the unit became busy.
One woman said: “I was misdiagnosed. It was reported as a 3B tear, but this was not the case. It was a large 3C, possibly a fourth degree tear… I live in fear and embarrassment of not being able to make it to the toilet in time.
“I spent the first one-and-a-half years thinking it was normal for professionals, a professional who falsely blamed my ethnicity for tearing. That it was normal for Asians to tear because we have a short perineum. It was made out to be my fault.”
Families also raised concerns about how the trust responds when things go wrong.
They described "superficial" investigations which offered general reassurance about learning rather than clear explanations of events or decisions, and complained that meetings were held without senior staff with the authority or detailed knowledge to answer their questions.
One parent said: "The senior team are not visible… not one of them was there... they are the people that need to see what's going on."
Staff under constant pressure
Staff working in BHRUT’s maternity and neonatal units told the investigation they are trying to provide safe, compassionate care in a service under “constant” pressure, with more births, longer stays and increasingly complex cases.
Midwives and doctors described a daily ‘balancing act’ in triage, the induction suite and theatres, where too many women arriving at once or beds being full can lead to delays in assessment, pain relief and basic checks.
On the postnatal ward, it was reported that midwives can be responsible for several new mothers and babies alongside medication rounds and discharge paperwork, meaning women may wait longer for help with feeding or symptoms that later prove serious.
Some staff admitted that during shortages, documentation, debriefs and even routine observations can be missed, raising the risk that a woman or baby becoming unwell is not spotted in time.
“Working while tired or not having time to do safety checks… could lead to mistakes being made,” the report notes.
Improvements not yet felt by families
Despite this, the report does note improvements and a shift in culture.
The executive team told investigators they have increased staffing numbers and reduced reliance on agency staff, and are “moving away from a ‘bums on seats’ approach” towards placing people with the right skills where they are most needed.
Staff spoke of a move from blame to “learning and support”, with leaders more visible and approachable and more forums to raise concerns and share good practice.
“I can confidently tell you the leaders that we have within our midwifery now, I can go to anyone’s office and open the door to say, ‘I’m concerned about X, Y and Z’, and they will listen to me,” one member of staff said.
However, investigators warn that these improvements are not yet consistently visible to women and families, and that numerical staffing “on paper” does not always match the reality of care experienced on the ground.
Baroness Amos’ report concluded: “For families, the evidence points to a simple need, people must be listened to, believed and treated with kindness, especially when they are scared, in pain or grieving.
“When women and birthing people are not listened to, this is a safety issue that increases risk.”
Preventable deaths
In the past six months, the Romford Recorder has reported from three inquests into baby deaths at Queen's Hospital which highlighted a pattern of failings.
In January, east London area coroner Nadia Persaud ruled that the death of baby Ada Rose, born at Queen’s Hospital in October 2024 was "preventable".
In June, the same coroner ruled that neglect by Queen’s Hospital maternity staff had contributed to the death of six-day-old Zachariah Orefuwa Millin, who was also born in October 2024.
Zachariah’s mum said: “The pain of hearing how different actions by maternity staff could have saved Zachariah is overwhelming. We have relived every terrible moment, minute by minute during the inquest.
“We are immensely private, but I make this comment in the hope of supporting other Black and Asian women who are dismissed or treated inappropriately by hospital staff.
“It is a pain that no family should have to endure, and we hope that the learnings taken from what happened to Zachariah will ensure better outcomes for other babies.
“Meanwhile, we treasure the precious moments we had with our baby. Our hearts ache every day, and he will forever be remembered as our perfect baby boy.”
In the case of baby George James Delaney, who died aged two days in September 2024, failures were highlighted in an inquest though a coroner concluded last month that on the balance of probabilities, these failures did not directly contribute to George’s death.
George's parents, Anita and Tomi, said: "Words cannot comprehend the pain we feel, we miss our son every day.
"We can now only hope that changes will be made in maternity care so that no-one else has to endure the heartache of losing a baby."
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