Overview

• The deaths of three newborns in Lanarkshire hospitals in 2019 and 2021 were deemed preventable if reasonable precautions had been taken.
• Key failures included inadequate midwife guidance, poor risk flagging, and misinterpretation of labour induction protocols.
• The inquiry issued 11 recommendations, including a 'trigger list' for preterm labour, a dedicated emergency phone line, and improved record-keeping systems.
• Parents of the deceased expressed grief and frustration over systemic failures, calling it a 'catalogue of errors' with missed opportunities to save lives.
• NHS Greater Glasgow and Clyde faces pressure to implement reforms aimed at improving maternity care and restoring public trust.