If Charlotte Bassett had known that her daughter Norah’s life would be numbered in hours and minutes, not decades and years, she’d never have left her side. But she didn’t. So Charlotte went to have a shower after Norah’s birth on 12 April 2019. When she came out of the shower, a junior doctor was assessing Norah, who was being looked after by her father, James Bassett. The doctor gave Norah the all-clear, and left them alone.

The maternity unit at the Royal Hampshire county hospital in Winchester was busy that evening. When the night shift came on duty, a midwife introduced herself. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned.

“I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. We are sitting in the Bassetts’ house in Eastleigh. By the window is a display case. It has photos of Norah in it, locks of her hair, her handprints. Her ashes.

“She’s wonderful, isn’t she?” says James, 40, a travel industry manager, gesturing to the cabinet. “I’m so proud of her.”

At about 9.30pm, nearly two hours after the doctor assessed her, Norah started grunting. “I’m sorry,” says James. “I can’t repeat the sound.” Charlotte went out to the desk. The midwives ran to Norah. “It was a shit show,” says Charlotte. “They were making notes on scraps of paper.” Norah was taken to neonatal intensive care.

As they waited for news, the same midwife came back. “She went, ‘Oh, it’s so busy tonight. I’ve got all these sheets to wash,’” says Charlotte. James went into the bathroom. He got down on his knees and prayed to a God he didn’t believe in to trade places. Let Norah live. Take him instead.

Norah died shortly before midnight. “The scream I let out,” says Charlotte, softly. “They do it really well on TV sometimes.”

A report into Norah’s care was produced in 2020 by the maternity investigations team of the then Healthcare Safety Investigation Branch (HSIB).

One sentence leaped out to Charlotte and James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter.

“So Charlotte spent four years in agony,” says James, “thinking it was her.”

* * *

Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says.

Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”.

Of this meeting, a Hampshire hospitals NHS foundation trust (HHFT) spokesperson says there was evidence of “tension on both sides”.

Derinell Haikney, a midwife, was not invited to the meeting. But she says she overheard some senior midwives as they prepared to go in. “They said, ‘He won’t know what’s hit him.’ They’d written all over his guidelines in red pen.”

Relations between Pitman and some of these senior midwives was fraught. Most of them didn’t work clinically on a day-to-day basis – “on the shop floor”, in NHS speak – but ran HHFT’s maternity services across three sites in Basingstoke, Winchester and Andover. A month earlier, on 7 March, Pitman had met the trust’s head of midwifery to discuss his concerns.

“The morale of the midwives was deteriorating,” says Pitman. “Sick leave rates were going up. We were starting to have challenges getting inductions done on time. You’d come in to do elective C-sections and be told you couldn’t do them because we didn’t have a midwife for your surgical list. If we didn’t do something, we were going to start to get avoidable disasters.”

The problems started in 2012, when the Basingstoke and North Hampshire hospitals NHS foundation trust merged with the Winchester and Eastleigh healthcare NHS trust. In Winchester, staff felt it wasn’t a merger, but a takeover. Midwives in management positions tended to come from Basingstoke. They introduced an unpopular on-call policy. Staffing was a problem, and some midwives felt that vacancies weren’t being advertised fairly. In 2019, some Winchester midwives took their concerns to Pitman, and he relayed these concerns to the head of midwifery, including telling her that she might be subject to a no-confidence vote.

But to the trust’s head of midwifery, the 7 March meeting felt like a personal attack. She left in tears. Six weeks later, on 21 April 2019, along with the joint deputy heads of midwifery and one consultant midwife, she made a formal complaint of bullying and harassment against Pitman.

An investigator was brought in to assess their complaints. They told her that they felt Pitman did not respect their professional expertise. He was hostile in meetings. He wrote ranting emails. (“HOW ARE YOU PROPOSING TO STAFF THIS SERVICE,” read one.) He gossiped about them. “He’s very good at bamboozling people with evidence that isn’t necessarily valid to get his way,” said one complainant. The issues were longstanding. In August 2018, some of these senior midwives had a meeting to discuss their concerns about Pitman and other obstetricians with hospital management.

The outside investigator also spoke to other doctors. While none described Pitman as a bully, they said he could be uncomfortably forthright, even antagonistic. His boss described him as someone who wasn’t good at seeing other people’s points of view, but said that “his heart is absolutely in the right place. It’s always about patient care”.

The investigator concluded that Pitman wasn’t deliberately trying to bully or harass these senior midwives, but that his “style of communication is a challenge”, and this had significantly harmed his complainants.

But the investigator also found evidence that Pitman wasn’t solely the problem. She concluded that some of the senior midwives who had made the complaint against him were disconnected from certain members of their team, and these junior midwives felt disempowered as a result. She also heard evidence that some senior midwives had behaved unprofessionally to Pitman at a foetal monitoring meeting on 4 April.

At the trust’s request, Pitman underwent behavioural coaching and mediation with his complainants. Due to poor mental health – he says the pressure of the investigation made him near-suicidal – he would not return to work until September 2020. Within two years, his 20-year career as an obstetrician and gynaecologist was over.

* * *

After the Bassetts received the HSIB report, Charlotte “many times wanted to kill myself,” she says. The report identified failings in Norah’s care. The unit was short-staffed. Equipment was missing, or didn’t work properly. Most crucially, Norah’s doctor didn’t understand the significance of her having different oxygen saturations (SATs) in her hand (99%) and foot (88%).

A difference in SATs is an indicator of coarctation of the aorta, a congenital heart condition. The HSIB investigators found that Norah should have been referred to a more senior doctor for review, but she wasn’t. Had this happened, she might have lived.

And yet, despite multiple signs Norah was unwell – during the hours after her birth, she was observed to be blue, grunting, spitting up blood, failing to feed, and had different SATs – HSIB said that Charlotte had possibly inadvertently killed her daughter.

“Charlotte held Norah beautifully,” says James.

An HHFT spokesperson said: “We would like to express our profound sorrow at the circumstances that surrounded Norah’s death. The experience of Norah’s family, and the extent to which our support fell short, is heartbreaking.”

James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them.

“I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says.

“I remember having meetings with my local MP,” says James Titcombe, a patient safety campaigner, “and basically being treated like an angry dad who was full of vengeance.” Titcombe’s son Joshua died in 2008 in Furness general hospital in Cumbria, after staff failed to spot he had sepsis. His campaigning led to the 2015 Morecambe Bay investigation, which found that one mother and 11 babies would have survived if given better care.

“I went through a period after the Morecambe Bay report was published of feeling hopeful,” says Titcombe. “But over the past year, more red flags have been popping up.”

* * *

Of all the departments in a hospital, maternity units are uniquely staffed. Midwives oversee so-called “normal births”, meaning births in which women deliver their children vaginally, without interventions. Doctors mostly get involved when women have risk factors, if the baby is in distress or stuck, or if dangerous conditions develop.

For midwives, birth is a physiological process from which the majority of women and babies emerge unscathed. For doctors, more likely to attend high-risk mothers, a more medicalised, cautious approach is advisable. It is for this reason that doctor-overseen deliveries are more likely to result in interventions than those attended by a midwife.

Until the 19th century, women gave birth at home, under the care of midwives. Approximately one in 110 women died. Throughout the 19th century, doctors pushed midwives out, and by the mid-20th century, most women gave birth in hospitals. “We saw dehumanising treatment of women in hospital settings,” says Eliane Glaser, author of Motherhood: A Manifesto. Women were sedated and their babies delivered by forceps. Many women suffered lifelong injuries, including PTSD, incontinence and prolapse.

A movement to give women back autonomy emerged in the 1970s, led by second-wave feminists. Midwives were handed back control of “normal births”. In 2005, the Royal College of Midwives started campaigning for “normal births” without interventions such as epidurals, inductions and caesareans. This normalising agenda was rolled out nationally in the 2010s. In 2012, NHS England set hospitals a 20% C-section rate target.

In Hampshire, there was also a push for normal births. One doctor at the trust would later describe it to investigators as “ambitious from a safety perspective”. In his department, Pitman was known for being sceptical when high-risk women chose vaginal births. His C-section rate was higher than that of other doctors. In the 2019 complaint made against Pitman by the senior midwives, this was a source of tension. One of Pitman’s complainants was jarred by a comment he made about how he didn’t care what the caesarean rate was, only about outcomes.

In a well-functioning hospital, doctors and midwives work side by side to provide the best care for their patients, regardless of their ideological differences. “But these power dynamics remain,” says Glaser. “Doctors still have more medical training [than midwives]. And so there remains a real sensitivity around this idea of power and control.”

* * *

The first time we meet, Pitman picks me up from Winchester station in his car. He wears a baseball cap, which reminds me of a celebrity escaping the paparazzi, or a fugitive on an Interpol watch list. When Pitman returned to work in September 2020, “there was this really uncomfortable feeling that every single thing that I did was being monitored”. The trust denies Pitman was monitored upon his return to work and the allegation was found to be without foundation by an employment tribunal.

In March 2021, Lucy Howell, 32, died in Winchester hospital while giving birth to her second child. She had previously had specialist surgery to repair a scar from a former C-section. She had been cleared by doctors to have a vaginal birth, and her labour had been induced with Syntocinon, a drug that increases the risk of uterine rupture, particularly in women who have previously had C-sections. Howell suffered a uterine rupture and amniotic fluid embolism. Her daughter, Pippa, survived.

Pitman says that when he went in to the department that day, a senior doctor described the situation as a “disaster”. He later reviewed Howell’s notes. “She’d had experimental surgery,” says Pitman, “after a C-section. What the hell was she labouring for? And why was she being given Syntocinon?” Pitman later whistleblew to the trust about Howell’s care. He is convinced that this, along with his history of whistleblowing dating back to 2019, meant he was unfairly treated by HHFT, and eventually led to him being fired.

The trust says that Pitman was not victimised for whistleblowing. Instead, it says that he was missing clinics (Pitman says they were done remotely due to Covid), was rude to a matron, and didn’t engage with his work plan or answer emails from management. Concerns had been raised about Pitman’s behaviour by his colleagues months before Howell’s death. In May 2022, the trust paid an external firm, Ibex Gale, more than £30,000 to investigate Pitman’s working relationships.

The Ibex Gale investigators spoke with 10 witnesses put forward by the trust, and 13 more of their own choosing. Pitman submitted a list of 19 witnesses to speak on his behalf; investigators elected to speak with five.

“Ibex Gale categorically refutes any suggestion that its selection of witnesses in Mr Pitman’s investigation was unfair,” says an Ibex Gale spokesperson. “The investigator’s choice of witnesses focused on members of staff that Mr Pitman worked with on a regular basis and on those working relationships that were fundamental to patient safety, the cohesion of the department and the effective delivery of the service.”

One trust witness had met Pitman just once, an encounter in which he was cordial, but she characterised their relationship as “negative”. His perceived hostility towards “normal birth” again emerged as a point of tension: a staffer told investigators of her frustration when Pitman would write “not suitable for home birth” on women’s notes. Some of his consultant colleagues described him as a superb doctor, but someone who had become like a black cloud hanging over the department. They say he made comments to them about wanting to take the trust down.

In some ways, Pitman was a dark cloud. He had a sense – perhaps justifiably – that he had been wronged, and this made him bitter. Ibex Gale found that Pitman’s working relationships had broken down with five individuals and that this could pose a threat to patient safety. All but one were in management positions. The investigators dismissed Pitman’s claims that the investigation was retaliatory because of his whistleblowing.

Having once been the person raising concerns about patient safety, Pitman himself was now the problem. He was fired in March 2023.

In calls with senior figures at the trust, Pitman is presented to me as, basically, an ogre. But the glowing accounts I hear from eight current and former HHFT midwives and maternity support workers are so dissonant that it is as if there were two Dr Pitmans striding the wards at the Royal Hampshire county hospital: one cruel and belittling; the other genial and kind.

“He was the most gentle, lovely, approachable person that I ever worked with at Winchester,” says Joy Danby, former maternity support worker at HHFT. “He was always approachable, honest, and supportive,” says maternity support worker Sandra Brookman. “From the get-go, he was, ‘I am Martyn. Never Dr Pitman,’” says Haikney. “I’ve spent 43 years in the NHS. Martyn is not one of the bad guys. And there have been some.”

* * *

Before she died, Howell sent her husband, Matt, a WhatsApp message. She wasn’t sure whether to have a vaginal birth. “What if I die?” she wrote. At the inquest into Howell’s death, the court heard that Shaheen Khazali, the surgeon who carried out her specialist obstetric surgery in 2019, had told her she should have a C-section with any future pregnancies.

Howell subsequently fell pregnant. Her obstetrician, instead of writing to Khazali for his recommendation, discussed her case in a corridor with a senior colleague who had witnessed her surgery. The colleague said to treat Howell the same as any other woman attempting a vaginal birth after one C-section. None of Howell’s doctors ever contacted Khazali.

A senior doctor told the court that she advised Howell’s obstetrician to update her medical notes after her death to ensure they were accurate, a decision the coroner said was “odd” and “not appropriate”. (HHFT says this was so that detailed records would be available to assist any investigation.) This doctor also said Howell should have been told that the vast majority of women in her situation had C-sections, but she was not. An HSIB investigator found that staff missed signs that Howell’s uterus was about to rupture.

The coroner determined that “none of those obstetricians involved in the birth had experience of this kind of history or the risk of rupture that this posed. Had they known and conveyed this information to Lucy she may have chosen to have an elective caesarean.” However, the coroner also said that Howell might have died of an amniotic fluid embolism even if she’d had a C-section, meaning that her death may not have been avoidable.

“It’s the way you counsel people,” says one current HHFT midwife. “If you say, ‘It’s a one in 200 risk, you’ll be fine,’ people will go for it. But if you say, ‘This could kill you,’ they might think, ‘I won’t take the risk.’”

The midwife is bemused by the inquest verdict. “Ludicrous,” she says. “If she’d had an elective section she’d probably be at home right now with her children.” Howell’s widower, Matt, told the court that she would have been willing to have another C-section, if doctors had advised her during her pregnancy to do so.

A trust spokesperson said Howell’s death was “entirely unforeseen and shocking” and offered its sincere condolences to her family.

Howell opted for a vaginal birth without being fully informed of the risks. Every day, pregnant women make similar choices, sometimes influenced by a “normal birth” ideology that is promoted in antenatal groups, by social media influencers and in hospitals all over the country.

In every maternity inquiry that has concluded since 2010, investigators found that a pro-“normal” birth culture contributed to avoidable deaths of women and babies. In 2017, the Royal College of Midwives ended its campaign for normal births, and in 2022, NHS England dropped its 20% C-section rate target. “People are very careful now about using the right kind of language, and not saying ‘normal’ births are better than medicalised births,” says Glaser.

But in practice, this attitude persists. “Women are still being given strong but subtle messaging that a ‘natural’, ‘normal’ delivery is better than having a medicalised delivery,” says Glaser. “Somewhere in the system, there’s a resistance towards really dismantling the privileging of natural birth.”

There is a reluctance to talk about this, because an attack on “normal birth” ideology can feel like an attack on the profession of midwifery itself, even if it is not. This is a profession that is mostly female, that works 100,000 unpaid hours a week, that is burnt out and quitting in droves. England is short 2,500 midwives. “People [are] doing their best, but they are exhausted,” says Ockenden.

But the situation is critical. Women are having children later, meaning that they are more likely to be high risk. “Doctors and midwives need a common view of what good maternity care is,” says Titcombe. “Because when things go wrong, they go wrong very quickly. The safe outcome depends on things that the normal birth approach pulls against.”

* * *

After Norah died, James and Charlotte considered litigation, but decided to focus on their daughter Hope, born in 2020. Charlotte also felt she couldn’t sue – after all, HSIB had suggested it may have been her fault. “I feel so guilty,” says Charlotte, “for not fighting for her.”

In September 2023, Charlotte and James saw Pitman on the news. He was taking HHFT to an employment tribunal, alleging that he was victimised as a result of whistleblowing about patient safety. Outside Southampton magistrates court, current and former staff members waved signs reading “We support Martyn Pitman”. Many were members of a Facebook group with 1,900 members. Some were so worried about being spotted by hospital managers that they came in disguise. “What does that say?” Haikney observes. “He’d already gone. So he clearly wasn’t the problem.”

By now, many of Pitman’s concerns had been proven. In November 2021, the Care Quality Commission (CQC), which inspects NHS hospitals and now oversees maternity investigations, downgraded HHFT’s maternity services from “good” to “requires improvement”. The CQC found there weren’t enough staff to keep women and babies safe. Midwives were exhausted and sepsis was being missed.

“If you are concerned that women’s and babies’ lives are at risk and you feel you are not being listened to, what are you expected to do?” says Titcombe. “As someone who has lost a baby, I would want someone in Martyn’s position to raise the roof.”

HHFT says its maternity services are fully staffed, and a yet-to-be-published CQC reinspection in December 2023 found them to be safe. But current midwives say that staffing is still a problem. “There are fabulous doctors and staff,” says Haikney, who retired last year. “The majority of the consultants are very good at Winchester. It is the management that is the problem.”

Pitman lost his tribunal. The court ruled that he was not unfairly treated for whistleblowing. He had planned to bring a separate unfair dismissal claim against the trust, but has dropped it: he is worried, he says, about the trust pursuing him for costs. Just 3% of whistleblowing claims are successful at tribunal. HHFT has spent about £450,000 related to Pitman’s employment issues. “You can’t fight the NHS,” says Brookman. “That’s how it is.”

HHFT says that this “independent judicial process confirmed what this trust has consistently said: Hampshire Hospitals has never, and would never, treat anyone negatively for raising safety concerns. We value and appreciate everyone who speaks up … no matter how brilliant or well qualified, every employee needs to operate with respect for colleagues”.

On 4 January 2024, the trust’s CEO, Alex Whitfield, gave an interview to the BBC. “This is a safe place to have your baby,” she said. A midwife working that day tells me that she was in tears because she was so overworked. “It takes a lot to break me,” she says, “but I was ready to walk out.”

A month later, some disturbing data was presented at a meeting in the trust. The rates of babies being born with brain injuries due to oxygen deprivation at birth had increased. The situation, staff were told, was under review. The HHFT said initially that this change was not “a significant statistical rise”. However, when pressed, it confirmed that the number of babies born in 2023 with hypoxic-ischemic encephalopathy, or brain damage due to lack of oxygen, was five times greater than the number born in 2022.

“We are undertaking a review to ensure we have a fully informed understanding of potential causes for this,” says an HHFT spokesperson.

* * *

Of the Royal Hampshire county hospital, Charlotte says that she and James “would like it to be known they have dangerous practices there”. She adds: “The most validating thing would be if someone from the hospital said, ‘Yes, I see we contributed to Norah’s death and we’ve changed.’” HHFT’s internal report into Norah’s death identified no serious errors in her care.

At the couple’s request, I sent Norah’s medical notes to a paediatric cardiologist for review. “She definitely wasn’t smothered,” he said. “It’s a bonkers suggestion.” He said that if Norah had received prompt care when the junior doctor recorded that she had different oxygen saturations in her arms and legs, including treatment with the drug prostin, she might possibly have survived.

“It will always be the four of us,” says James. “We are learning to be a parent to a child that is dead as well as a child that is alive. I think about Norah every moment of the day.”

In December 2023, the CQC reinspected Hampshire’s maternity services. A trust spokesperson says that it found them to be safe, although this inspection has not yet been made public and officially signed off by NHS England.

But across the country, England’s maternity services are in crisis. Morecambe Bay. Shrewsbury and Telford. East Kent. Donna Ockenden, who is currently investigating Nottingham’s maternity services, has been contacted by hundreds of families: it’s likely to be the biggest maternity scandal in NHS history. Nottinghamshire police have launched a criminal investigation into severe harms and deaths linked to maternity care provision at the Nottingham University hospitals trust. There are rumblings about Cheltenham, and Hull. The Maternity Safety Alliance is calling for an urgent public inquiry into maternity safety in England. The system, it says, is “fundamentally broken”.

Joshua Titcombe died in 2008. Since then, we have had nearly two decades of dead women, dead children, disabled children, traumatised and physically injured mothers. Thousands of avoidable catastrophes. Each of them a specific horror, but the contours of these stories are the same. Understaffed maternity units with doctors and midwives run ragged. Experienced midwives quitting the profession, because they can’t take it any more. NHS trusts preoccupied with reputation management over patient safety. Whistleblowers forced out. A culture of promoting normal births at all costs.

Nearly two-thirds – 67% – of England’s maternity services are not safe enough, according to CQC figures. The NHS paid out £1.1bn in 2022/23 on maternity-related negligence claims. In 2021, a parliamentary committee urged the government to invest an extra £200m-£350m annually to safely staff England’s maternity units. It invested £186m. The outgoing NHS ombudsman recently warned that NHS leaders sometimes lie and conceal evidence when it comes to maternity care. Meanwhile, women are dying: maternal deaths are up 53% in the period 2020-2022 compared to 2017-19.

From Cumbria to Hampshire, Kent to Shropshire, the issues are universal. Any woman, in any hospital, having any baby, could be at risk.

“The truth is,” says Titcombe, “the majority of England’s maternity services are unsafe. If you got Ockenden in, and scrutinised everything, stuff would come out. There’s this fallacy that we’ve had a few scandals. It’s nonsense. The problems are everywhere.”

As for Pitman, his career is over. “I still got the same buzz from delivering my last baby that I got from my first. I’m very proud of that,” he says.

Before I leave, Pitman shows me a box. There are hundreds of thank-you cards in it. Photos of schoolchildren and beaming families on the beach. All babies he delivered safely. “These are the opinions that matter,” says Pitman, and for once, the doctor is silent.

• This article was amended on 26 March 2024. An earlier version suggested James Titcombe was speaking in his role with the campaign group Patient Safety Watch. To clarify, he was speaking in a personal capacity. Also, the Health Services Safety Investigations Body (HSSIB) did not take over maternity investigations from the Healthcare Safety Investigation Branch; they are now overseen by the Care Quality Commission.

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