At least 58 babies at an NHS maternity unit might have survived with better care, a BBC investigation has found.
The deaths included 32 stillbirths and 26 neonatal deaths – which is a death within 28 days – at Oxford University Hospitals Trust (OUH) between 2019 and 2024, according to a Freedom of Information request.
Bereaved and harmed mothers have blamed missed chances, « arrogance » among some senior doctors and a « defensive culture ».
In a statement, OUH said it was sorry some mothers have had experiences that have left them feeling this way.
It added the figures included mothers and babies who were referred to the trust for specialist care from across the region and every baby death was reviewed in detail to « fully understand what happened and whether improvements are required ».
Eleanor Taylor-Verlaan is booked in for a Caesarean section next month, two days after the anniversary of the death of her first daughter in 2017.
Baby Alissa suffered severe brain damage due to a lack of oxygen caused by the placenta coming away from the womb wall.
Eleanor believes with better care her daughter might still be alive.
« They should’ve got me in straight away, they should’ve seen me as soon as I turned up to hospital because I was classed as high risk, they should have listened to the midwives that were watching that CTG (cardiotocography) quite closely but everything got overruled [by the doctors], » she told the BBC.
Eleanor, 27, from Faringdon, Oxfordshire, said her 20-week scan detected she was at a higher risk of complications including growth restriction, pre-eclampsia and stillbirth, but she was not closely monitored.
At 35 weeks, she complained to midwives about abdominal pains and sickness but was told to stay at home and take paracetamol.
On 20 February 2017, after waiting more than two hours in the maternity assessment unit, her baby was delivered by emergency C-section in a poor condition. Alissa passed away six weeks later.
An internal review, seen by the BBC, identified some care issues but concluded it was unlikely they would have « improved the outcome for this baby ».
Eleanor said she did not know how to ask for an independent investigation at the time but now hopes to challenge the findings with the help of birth injury lawyers.
Laura Cook, a partner at Medilaw, told the BBC: « They carry out a tick-box exercise with internal reviews to look like nothing could have been done, it forces families to go to lawyers who then find there’s more to it… it puts families through hell.
« What stands out with Oxford is its defensiveness, it’s clear that reputation is of the upmost importance, it’s not the same with other trusts. »
The trust said it recognises some families remain dissatisfied and it takes feedback seriously.
The BBC investigation also found:
OUH said its claims-per-birth rate was among the lowest compared to similar trusts that handle the most complex cases.
It added compensation figures often related to incidents from many years earlier and can be skewed by one or two high-value cases involving life-long care needs.
Between 2019 and 2024, OUH carried out 361 internal reviews into baby deaths – known as Perinatal Mortality Review Tools (PMRTs).
At least 58 cases were graded C or D, indicating that different care either « may » have or was « likely » to have made a difference to the outcome.
For context, separate BBC investigations have found 56 baby deaths in Leeds may have been preventable over the same period, and 55 babies may have survived with better care in Sussex between 2019-2023.
It was estimated there were more than 800 preventable baby deaths across the UK in the NHS in 2023 and 2024, according to the Sands and Tommy’s Joint Policy Unit.
The CQC was given powers to prosecute trusts for serious failures in care in 2015, to date there have been five prosecutions.
Alice Topping had also been identified as high risk for complications at her 20-week scan and had been referred by her midwife for an extra scan at 40 weeks due to concerns about her baby’s growth.
When she was not contacted, she repeatedly tried to book one in, calling 44 times in one day.
But Alice says the request was turned down by a consultant who told her the trust prioritises scans at 36 weeks instead.
A week later her daughter Smokey died during labour at the John Radcliffe Hospital in Oxford in September 2023.
« At the most vulnerable time in my entire life I was failed… it’s just horrific knowing that with just basic care my daughter should be here, that’s not acceptable, » Alice said.
She said an internal review found the trust did nothing wrong, but an independent investigation showed « a catalogue of failings » and made five safety recommendations which « could have made a difference to the outcome ».
Alice believes vital information about her risk was kept from her, she says bereaved and harmed families « deserve answers, truth and change ».
In 2023, the year Alice lost her daughter, OUH had the highest stillbirth rate compared to 25 specialist trusts that care for the sickest babies.
According to the latest figures from MBRRACE-UK – which monitors and investigates the deaths of mothers and babies – its stillbirth rate in 2024 fell slightly from 3.6 to 3.47 per 1,000 births which was in line with comparable trusts while its overall mortality rates were below average for similar units.
The trust sees more than 7,000 births a year, the vast majority are safe and many women have reported receiving good care.
The health watchdog, the Care Quality Commission (CQC), inspected the trust’s main maternity unit at the John Radcliffe Hospital in Oxford in 2021 after five whistleblowers contacted them raising concerns about bullying and dysfunctional teams.
Its rating was downgraded from Good to Requires Improvement.
Since then, OUH has been receiving targeted maternity support from NHS England which will remain in place until June.
NHS England said this was to « ensure timely induction of labour decision-making and strengthening of management and oversight to improve the safety and quality of care for women, babies and families ».
CQC inspectors returned in October 2025, but the results have not yet been published.
It issued a warning notice on 8 December 2025 after the CQC identified five breaches of legal regulations in relation to safe care and treatment, premises and equipment, good governance and staffing.
A campaign group, Families Failed by OUH, is calling for a judge-led public inquiry into OUH.
Health Secretary Wes Streeting granted independent reviews into hospital trusts in Leeds and Sussex but so far there are no plans for an investigation in Oxford.
Michelle Welsh MP, who chairs the All Party Parliamentary Group on Maternity, says that needs to change: « There is a systematic toxic culture there that needs tackling and families deserve accountability and answers. »
OUH is one of 12 NHS trusts under a national review of maternity and neonatal services due to conclude in June.
A spokesperson for the Department for Health and Social Care said Baroness Amos would « set out clear steps to improve maternity and neonatal care across England ».
« NHSE has also placed OUH on a programme to provide rapid, targeted support to maternity services, with regular meetings bringing together hospital leaders and national experts to make sure progress is being made, » the spokesman said.
Responding to our investigation, Simon Crowther, interim chief executive for OUH, said the stories shared with the BBC were « tragic » and he recognised the lasting impact of losing a child.
He said the trust was willing to look at Eleanor’s case again and urged her to contact them.
He added that Alice’s case was complex and had been examined by several independent bodies.
« The trust remains fully committed to learning from every family’s experience and to continually improving the safety and quality of maternity care, » he said.
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