A Parliamentary and Health Service Ombudsman investigation upheld five out of seven complaints against Royal Cornwall Hospitals NHS Trust — finding breaches of NICE, NMC, RCS and GMC standards. We believe our experience is not isolated. This site exists to gather those stories.
The NHS scandals at Morecambe Bay, Shrewsbury and Telford, and Nottingham were not uncovered by regulators — they were uncovered by parents who refused to stay silent. We are doing the same.
When injuries are psychological — PTSD, postnatal depression, anxiety — families face an additional barrier: the legal and financial framework treats psychiatric harm as worth significantly less than physical injury. This must change.
A birth plan is a legal and ethical expression of a patient's wishes. Evidence shows that documented preferences are routinely overridden — often with no explanation, and no record of why.
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Treliske — Royal Cornwall Hospital, Cornwall
We are Sian and Jon, and our story began in December 2022 during the birth of our daughter at Treliske.
In December 2022, our daughter was born at Treliske — Royal Cornwall Hospital in Cornwall. It should have been the most joyful night of our lives. Instead, what followed was a failure of care that has had lasting consequences for our family.
Sian arrived at Treliske in the evening. Despite being in established labour, the Trust failed to recognise this for almost three hours. Sian initially asked for pain relief, including gas and air, but was told no because it can sometimes make people go ‘crazy’. Gas and air was eventually provided, but was withheld again while she was transferred upstairs. After what had been said, Sian also felt reluctant to use much of it. Further pain relief was only provided once staff realised she was fully dilated and actively pushing.
Sian had a carefully prepared birthing plan. It documented her medical history, her wishes, and — critically — her explicit refusal of certain examinations. Those documented wishes were repeatedly ignored.
When Sian required surgical intervention, the operating surgeon was not aware of a significant aspect of her medical history. During labour, we were told a meconium-contaminated sample would be tested. Only through the complaints process did we later discover it had never been tested at all, because such samples cannot be accurately analysed. This raised serious concerns around communication, staff knowledge, and record keeping.
In the days and weeks that followed, Sian was diagnosed with PTSD, postnatal depression, postnatal anxiety, and OCD. The impact on her health, her confidence, and her ability to work has been profound and ongoing.
We made a formal complaint to Royal Cornwall Hospitals NHS Trust. We were not satisfied with their response, so we submitted a second formal complaint — giving the Trust a second opportunity to respond properly. We were still not satisfied. We escalated to the Parliamentary and Health Service Ombudsman. After a full investigation, the Ombudsman upheld five out of seven of our complaints — finding that the Trust had breached NICE, NMC, RCS and GMC standards of care.
The financial remedy offered was £1,200. We consider this wholly inadequate for the harm caused.
We also sought legal representation on a no-win-no-fee basis, but were turned down by multiple solicitors. Part of this was because pursuing claims for psychological harm such as PTSD, postnatal depression, and anxiety is often far harder within the legal system than pursuing claims for physical injury. This is wrong, and we are calling for it to change. In addition, by following the Ombudsman process first, the case had gone beyond the three-year limitation period by the time we approached many firms. Several solicitors told us this alone prevented them from taking the case forward, which we feel is deeply unfair. Our search for a solicitor is still ongoing.
We share this not for sympathy, but because we believe we are not the only family this has happened to. Major NHS maternity scandals — Morecambe Bay, Shrewsbury, Nottingham — were not uncovered by regulators. They were uncovered by parents who refused to stay silent.
We are not staying silent.
Five upheld complaints. Four regulatory standards breached. One Trust that needs to do better.
In January 2026, the Parliamentary and Health Service Ombudsman completed its investigation into our complaint against Royal Cornwall Hospitals NHS Trust. The Ombudsman upheld five out of seven complaints. The following failures were formally identified:
Sian arrived at Treliske in the evening and was already in established labour. The Trust failed to recognise this for approximately three hours. By the time they finally recognised that Sian was in labour, she was fully dilated and pushing. This was a serious clinical failure with direct consequences for everything that followed.
During hours of active labour, pain relief was not appropriately provided. Sian initially requested pain relief, including gas and air, but was told no because it can sometimes make people go ‘crazy’. Gas and air was later provided, but then withheld again during transfer upstairs, and after those comments Sian felt reluctant to use much of it. Further pain relief was only provided once staff realised she was fully dilated and actively pushing. We do not believe these were appropriate reasons or circumstances in which to deny or delay pain relief to a woman in active labour. This is not an appropriate clinical reason to deny pain relief to a woman in active labour.
Sian had a formal birthing plan documenting her explicit refusals of certain examinations. Staff made repeated requests that directly contradicted her documented wishes — a failure of patient-centred care and of basic professional standards.
The operating surgeon was not aware of a significant aspect of Sian's medical history prior to operating. This is a fundamental requirement of safe surgical practice and a clear breach of RCS and GMC guidance.
During labour, meconium was discovered in a urine sample. We were told it would be sent for testing, but heard nothing further at the time — and were offered no reassurance or support. Only through the complaints process did we later find out the sample had never been tested, because it cannot be accurately tested when contaminated with meconium. This should have been known and explained at the time — it revealed inaccurate training, a lack of knowledge, and a failure of communication within the team. Record keeping throughout was found to be poor.
What the Ombudsman required
The Ombudsman required the Trust to issue a written apology, produce an action plan within three months, and update its surgeon review policy to align with RCS and GMC guidance. We will be monitoring whether the Trust meets these requirements — and making the outcomes public.
Stories shared by families who have experienced care at Royal Cornwall Hospital maternity services. Published with permission — anonymously or named, exactly as each family chose.
Stories will appear here as families come forward to share their experiences of RCHT maternity care in Cornwall. Each story will be published exactly as the family wishes — with their name, or completely anonymously. We will never publish anything without explicit permission.
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Accountability, transparency, and systemic change.
The NHS maternity scandals at Morecambe Bay, Shrewsbury and Telford, and Nottingham were all brought to light by families speaking out — not by regulators acting alone. We are doing the same. We believe other families in Cornwall have stories that deserve to be heard.
When the harm is psychiatric — PTSD, postnatal depression, anxiety — the legal and financial framework consistently undervalues it compared to physical harm. Families are failed twice: first by the care, and then by the law. We are calling for this to change.
A birth plan is a legal and ethical expression of a patient's wishes. We are calling for stronger enforcement of the duty to respect documented birth preferences — and for clear accountability when those wishes are overridden.
Working with the Birth Trauma Association
We are working with the Birth Trauma Association, who have supported our campaign and will be sharing Sian's story during their awareness week in July 2026, themed around the cost of birth trauma.
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