Less than a day after being told her baby had died in the womb, 39-year-old Jacqui Hunter was given medication to induce labour at Ninewells Hospital in Dundee. She experienced severe contractions, collapsed and suffered a cardiac arrest. Jacqui died a few hours later from an amniotic fluid embolism (AFE).
Her husband, Lori Quate, says he was not informed at the time that Jacqui had been given eight times the recommended dose of misoprostol, the drug used to start labour. He later found the overdose recorded in her notes only after she had died.
Lori said: "Not going to Jacqui, their patient, and saying we have messed up. Jacqui had a right to know about that, and they kept it from her."
An NHS Tayside review panel examined Jacqui's death in 2020 and noted that an AFE "can occur in any labour and it is not possible to be certain that in this case an AFE would not have occurred with the correct dose of Misoprostol". The panel also concluded that "as it is known that higher doses of Misoprostol increase the risk of AFE, the incorrect dose must be considered as a major contributing factor to AFE and subsequent death".
A subsequent fatal accident inquiry published its determination in 2024. It said it was possible, but not probable, that Jacqui's death might have been prevented had the correct dose been given. The inquiry did not make a ruling on whether the overdose should have been discussed with Jacqui before she died.
A spokeswoman for NHS Tayside said it was "deeply sorry" for Lori's loss, and that multiple internal and external reviews had been carried out, with accepted recommendations implemented to strengthen systems and care.
Across Scotland, health boards can carry out Significant Adverse Event Reviews (SAERs) when serious incidents affecting patient safety occur. Since 2020 there have been 143 SAERs relating to maternity care, with 44 of those in NHS Greater Glasgow and Clyde.
Independent inspections of maternity units were introduced recently in Scotland. The first such inspection examined the maternity service at Ninewells Hospital and identified a range of patient safety concerns, including staffing shortfalls and delays in assessing pregnant women.
Families and clinicians have described other incidents where care fell short. One SAER investigated the death of three-day-old Mason Scott McLean in 2023. After being discharged following birth, Mason became lethargic and disinterested in feeding. He was taken to hospital and later died; the review found errors including an incorrect temperature recording, incomplete records and missed tests that would have identified a life-threatening infection.
Mason's mother, Julie, who is an intensive care nurse, said of the hospital care: "It was the most basic nursing care and they would have known how sick he was." The SAER identified a number of systematic problems that may have contributed to his death.
Retired consultant neonatologist Dr Helen Mactier, who authored a review of neonatal deaths in Scotland, says that investigations are not always as thorough as they should be and that lessons are sometimes not widely shared.
She warned: "We find that serious adverse event reviews are not always undertaken quite as thoroughly as they might be and that the learning from these reviews is not always made."
Dr Mactier added: "It's very concerning that review after review says essentially the same thing. It says that we commonly fail to listen to patients." She also cautioned: "We get so tied up in protocols and systems and processes, that we actually forget to use our ears and listen to what the patient's telling us."
She urged action rather than further reviews to address what she described as "the systemic issues".
Some bereaved families and campaigners are pressing for a national inquiry in Scotland comparable to large-scale independent reviews under way in England. They point to a series of investigations there that have examined hundreds and in some instances thousands of cases where care failings were identified.
Reporters and campaigners note differences in how maternal and neonatal safety investigations are organised between Scotland and England. For example, England's Maternity and Newborn Safety Investigations programme completed hundreds of independent safety investigations in a recent year, while Scotland has relied more on local SAERs and has only recently begun unannounced maternity inspections.
Public Health and Women's Health Minister Jenni Minto highlighted long-term improvements and actions being taken in Scotland. She said: "We are committed to learning from every case to improve care, strengthen safety, and support women and their families.
"We are providing record funding to NHS boards and have strengthened guidance on SAERs to ensure lessons are learned and care improves continuously."
She also welcomed Healthcare Improvement Scotland's move to conduct unannounced inspections at obstetric units and said national maternity standards developed by HIS were expected to be published shortly. The minister cited safe staffing legislation and allocation of a primary midwife for every pregnant woman as examples of measures intended to raise standards.
Those affected by poor outcomes say they want clear communication, accountability and open explanations from health services. Dr Mactier said families are often seeking an apology and "an open and an honest" account of what happened.
For many of the families involved in these cases, the central demand is for changes that will prevent similar tragedies in the future rather than only more reports and reviews.