Bereaved Parents to Testify at Independent Review of Sussex Maternity Services

Background of the Independent Review

In early 2024 the UK government commissioned an independent review of maternity services in Sussex. The review is chaired by former midwife and public health expert Donna Ockenden, whose previous work on the Camden and Kensington maternity inquiry set a precedent for thorough, family‑focused investigations.

The review follows a public outcry after several infant deaths and stillbirths were linked to alleged shortcomings at the Royal Sussex County Hospital and other local facilities. Families, media outlets and health‑care watchdogs have called for a transparent examination of clinical protocols, staffing levels and communication practices.

Families Who Lost Children

Among the families willing to speak publicly is Susan Cacciacarro, who was 37 weeks pregnant with her daughter Chiara in 2021. She described waking one morning to a sudden absence of fetal movement, a sign that prompted an emergency visit but ultimately did not prevent tragedy.

“My belly just didn’t feel right. I didn’t feel any movements,” she recalled.

Other parents, such as the Patel family, lost their newborn son, Arjun, after a series of delays in diagnosing a heart condition. Their testimony highlights gaps in rapid response pathways that the review will scrutinise.

Key Issues Raised by Bereaved Parents

Parents who have spoken to the media and advocacy groups consistently point to three core concerns:

• Delayed or missed warning signs – families report that reduced fetal movement, abnormal heart rates or unexplained bleeding were not acted upon promptly.
• Communication breakdowns – many describe receiving conflicting information from midwives, obstetricians and neonatal teams.
• Staffing pressures – chronic understaffing and reliance on temporary staff are cited as factors that compromise continuity of care.

These themes echo findings from the National Health Service guidance on safe maternity care, which stresses early detection of fetal distress and clear, consistent communication with families.

Delayed or Missed Warning Signs

Research published by the Royal College of Obstetricians and Gynaecologists indicates that reduced fetal movement is a leading predictor of stillbirth. Yet several families say that their concerns were dismissed as normal variations, leading to missed opportunities for intervention.

Communication Breakdowns

Effective handover between shifts is a legal requirement under the NHS England standards. Parents allege that these standards were not consistently applied, creating confusion during critical moments.

Staffing Pressures

Data from the Office for National Statistics shows that maternity unit staffing ratios in Sussex fell below national averages in 2022 and 2023. This shortfall is believed to have increased workload for permanent staff and limited the availability of senior clinicians for complex cases.

Legal and Policy Context

The independent review operates within a framework established by the Maternity Services Review Act 2023, which mandates a public inquiry when systemic failures are suspected. The act requires that families be given a voice, that findings be published in full, and that recommendations be implemented within a twelve‑month window.

In addition, the UK government’s maternity strategy emphasizes patient‑centred care, safety audits and continuous professional development for staff. The Sussex review will assess how well local providers have adhered to these policy commitments.

What the Review Aims to Achieve

Donna Ockenden’s terms of reference outline four primary goals:

1. Identify systemic failures that contributed to infant deaths and severe complications.
2. Evaluate the effectiveness of existing risk‑assessment tools and escalation protocols.
3. Recommend concrete actions to improve staffing, training and communication.
4. Provide a platform for bereaved families to share their experiences and influence reform.

By focusing on both clinical and organisational factors, the review seeks to produce recommendations that are actionable and measurable.

Risk‑Assessment Tools

The review will examine the use of the “Maternal Early Warning Score” system, a tool designed to flag deteriorating conditions in pregnant women. Early analyses suggest inconsistent application across shifts, which may have delayed critical interventions.

Escalation Protocols

Escalation pathways dictate how concerns are raised to senior clinicians. Families have reported that these pathways were either unclear or ignored, a problem that the review will address through policy redesign.

Next Steps and Public Involvement

The first public hearing is scheduled for October 2024, where families like Susan Cacciacarro will give evidence under oath. The review panel will also invite submissions from health‑care professionals, advocacy groups and academic experts.

All evidence will be compiled into a final report due by June 2025. The government has pledged to allocate additional funding to Sussex maternity units if the report recommends structural changes.

Members of the public can follow the inquiry’s progress on the official website, which will publish hearing transcripts, interim findings and opportunities for comment.

For families still seeking answers, the review offers a formal avenue to have their stories heard and to influence future safeguards. As the process unfolds, the hope is that the lessons learned will lead to safer, more compassionate maternity care across the region and beyond.