Having a baby is an exciting, life-changing event and one that every mother wants to be a positive experience. Midwives play a vitally important role in this; they are the first port of call when you have a question and help you to make informed choices about your pregnancy and birth.
Unfortunately, as the health complaints body, we have come across cases where midwives have made serious mistakes which hadn't come to light before due to failings in the local midwifery investigation.
Sadly, one case we reviewed was of a baby who had died within 24 hours of being born due to being deprived of oxygen during the birth. The organisation responsible for investigating complaints and concerns about midwives - the Local Supervising Authority - reviewed the records and decided that there were no midwifery concerns that would warrant an investigation.
However we found that the baby's heart should have been monitored at regular intervals from the moment the mother arrived in the delivery suite. The fact that this was not done by the midwives should have prompted a decision to investigate.
We learned that the local organisation responsible for investigating complaints about midwives consisted of the supervisors of the very same midwives - people who provide them with support and guidance day in and day out. This relationship put the supervising midwives in an impossible position and highlighted a significant conflict of interest.
It's important to remember that the large majority of midwives provide excellent care and support to expecting mothers. Incidents like this are rare but nonetheless when they happen, they must be properly investigated.
As a result of our casework we made recommendations to government for change in our 2013 Midwifery supervision and regulation report. This would ensure that those who investigate serious concerns about midwives are separate from those who support them.
Today our recommendations have become reality improving safety for mothers and their babies.
This legal milestone would not have happened without the brave families who came to us seeking justice after suffering harrowing ordeals. We owe them a debt of gratitude.
It also shows that complaining can make a difference. Your experience may not be a one off - it could be part of a bigger problem where complaining will lead to change, preventing the same mistakes from happening to someone else.
We are all grateful for the NHS and the tremendous work our midwives do across the country. But this collective gratitude must not stop us from seeking to make further improvements, or speaking up when something has gone wrong.Suggest a correction