Hospital 'truly sorry' for stillbirth failings

A bereaved couple who suffered a stillbirth after their concerns were "dismissed" by midwives say they are devastated after the hospital acknowledged earlier interventions may have saved their son's life.

Joy Kabiri and husband Daniel Udoeyo want to see changes in the NHS to prevent similar tragedies happening to other families.

In letters seen by the BBC, Oxford University Hospitals (OUH) NHS Foundation Trust formally apologised for failings. In a statement interim chief executive officer Simon Crowther said the trust was "truly sorry that we did not get Joy's care right".

It comes as a national review into maternity and neonatal services found widespread discrimination and systemic failings.

Joy and Daniel, from Oxford, had been trying for a baby for four years and had even paid for IVF treatment abroad when they unexpectedly fell pregnant in spring 2025.

"It was a miracle, it was the best period of my life," said Joy, 33.

"We were so happy... because it was like a dream come true."

Joy previously underwent a procedure to remove abnormal cells from her cervix at the John Radcliffe (JR) Hospital, where she later received her maternity care.

It meant her pregnancy should have been treated as high risk.

Despite repeatedly informing multiple members of staff and midwives about her medical history she said it was never acted upon.

As her pregnancy progressed Joy began experiencing worrying symptoms, but she said her concerns were still repeatedly dismissed.

When she was admitted to the JR with heavy bleeding she said doctors told her she needed to be induced to save her own life.

Baby Elkan was stillborn at 20 weeks on 1 September.

"I tried my best, I played my part, I didn't want anything to go wrong," Joy said.

"I was always ringing the hospital and nobody took me serious. Even when I went in, nobody took me serious."

Following an internal investigation the hospital's chief nursing officer wrote to the couple acknowledging that Joy should have been placed on a "pre-term labour risk pathway".

The letter said she might then have been offered a scan and interventions which may have reduced the risk of pregnancy loss.

The trust also acknowledged that during one hospital attendance a "more cautious approach should have been taken" and that Joy "should have been offered a thorough examination and medical review".

It stated that learnings from the case had been shared with the maternity team.

Crowther said: "Our investigation identified poor communication and missed opportunities to refer Joy for additional special monitoring to reflect previous treatment she had received.

"This would have provided opportunities to detect concerns and consider further clinical review or intervention."

Joy and Daniel are committed to raising awareness of disparities in maternal and neonatal outcomes among Black and Asian communities.

Black women in the UK are nearly three times more likely to die during or shortly after childbirth compared to white women.

Black babies are also twice as likely to be born stillborn compared with their white counterparts.

Earlier this year, Baroness Amos's interim findings into national maternity and neonatal services found structural racism and persistent inequalities were leading to "notably higher risk of adverse outcomes" for women from Black and Asian backgrounds, and women from more deprived areas.

She told the BBC ahead of the publication of the National Maternity and Neonatal Investigation final report that her team spoke to families from a wide variety of diverse backgrounds, and that there was "concern that the outcomes that they see are worse than for the majority of women and families who are white".

"Discrimination, racism, are all having an additional impact," she explained.

OUH is one of 12 NHS trusts in the report. In it the JR is described as "old and not fit for purpose".

Families gave evidence of other women's blood and urine in the clinical areas and toilets at the site.

"In the delivery suite at the hospital there was blood splattering on the wall and on the ceiling," one witness is quoted as saying.

Baroness Amos cited "capacity pressures" across the service "affecting staff's day-to-day experiences", "unsustainable shift patterns where night-time cover is stretched thinly" and community midwives "under pressure".

She said staff told her they often got through shifts "by the skin of our teeth", and that while the executive team acknowledged some of this, she "did not consider that they fully understood the cause of the distress staff were experiencing".

The baroness also described relationships between the trust and many families as "fractured".

"Whilst the trust told us they are trying to bridge the gap with families, we remain concerned that the evidence we have heard from some families who have recently given birth at the trust is that they are still being dismissed, and staff are not listening to them," she said.

Crowther said his team was "deeply sorry" about the "harm, distress and loss" described in the final report, including the "confusing and inconsistent communication" and how care "was not always safe, compassionate or individualised".

"We will place the experiences shared with Baroness Amos and her team at the heart of our improvement plans," he added.

"Women, families and staff will be directly involved in informing, shaping and delivering the changes we make.

"We will listen, act honestly, and be open about the progress we are making and the progress we still have to make."

He also said the findings would be acted on "with urgency".

"To every woman, baby and family we failed, we are sorry. We have heard you, and we are determined to be the service you deserve."

Baroness Amos also called for the creation of a statutory national maternity and neonatal commissioner. In response the Department of Health and Social Care has announced the first-ever commissioner "to speak up for women, babies and families".

The Keep the Horton General campaign group believes the JR's maternity problems stem from downgrading the nearby Horton Hospital's consultant-led unit in Banbury to midwife-led.

Campaigner Beth Hopper told the BBC: "All those births now being channelled to the John Radcliffe means that they cannot cope with the birth numbers they're seeing.

"We have mothers who aren't being looked after properly, they're not being given food or water, pain relief... they don't have the staffing levels required to safely look after mothers and their babies.

"It's not acceptable in this day and age. It's traumatising for families and it's upsetting for everyone around them to hear."

Roseanne Edwards added: "We have warned time and time again since 2016 when the OUH said it was going to remove obstetrics from the Horton in Banbury that the JR would not be able to cope and mothers would suffer."

She said campaigners were "not happy to hear the consequences are as we predicted", including the "terrible" and "insanitary" conditions, the "stress on staff" and the "trauma" created "for mothers and their babies".

Amid their own loss, Joy and Daniel have set up the charity Elkan's Light in their son's memory to support Black and minority ethnic families, as well as raise awareness of the risk of cervical procedures during pregnancy.

"I'm hoping that things change because being in that room and seeing what she went through, it broke a part of me and it's not healed yet," Daniel said.

You can contact Katharine about this story by email katharine.dacosta@bbc.co.uk, or via instagram @bbckatharinedacosta