In May 2020, Jacqui Hunter, a 39-year-old expectant mother from Fowlis near Perth, Scotland, faced the unimaginable: just a week before her due date, she was told her daughter Olivia had died in the womb. Less than 24 hours after receiving this heartbreaking news, Jacqui herself died at Ninewells Hospital in Dundee. The tragedy stunned her family and quickly became emblematic of growing concerns over maternity care in Scotland.
According to BBC and the Daily Mail, Jacqui was administered Misoprostol, a drug used to induce labor, but was given a staggering eight times the recommended dose—400 micrograms instead of the standard 50. While Misoprostol is intended to help mothers deliver safely, higher doses are known to increase the risk of a rare, life-threatening complication called amniotic fluid embolism (AFE). Jacqui suffered intense contractions, collapsed into her husband Lori-Mark Quate’s arms, and went into cardiac arrest. Despite rapid intervention, she died within hours. Olivia, delivered stillborn, never had a chance.
What deepens the tragedy is that Jacqui was never told about the medication error. Medical staff at Ninewells Hospital were aware of the overdose before her contractions began, but the mistake was only recorded in her medical notes after she had died. Lori-Mark Quate, grieving the loss of both his wife and daughter, told BBC Disclosure, "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." He added, "In Jacqui's medical notes, there is no mention of that drug at all, at any point, until after she's declared dead and passed."
The aftermath saw a flurry of reviews and inquiries. An NHS Tayside review panel in 2020 acknowledged that while AFE can occur in any labor, the incorrect dose of Misoprostol "must be considered as a major contributing factor to AFE and subsequent death." The panel also stated Jacqui should have been informed of the error. A subsequent fatal accident inquiry, Scotland’s equivalent of a coroner’s inquest, concluded in 2024 that it was "possible but not probable" that the overdose could have prevented Jacqui’s death if the correct dose had been administered. However, it made no judgment on whether failing to inform Jacqui of the error impacted the outcome—a conclusion Lori described as a "whitewash."
NHS Tayside expressed its condolences, with a spokesperson stating, "NHS Tayside undertook a number of internal investigations and engaged in external reviews following the deaths to ensure all learning opportunities were taken by the organisation to deliver improvements. All recommendations identified in the reviews were fully accepted and, as a result, our systems and processes have been strengthened where required and improvements have been made to how we provide care."
This case is not an isolated incident. According to BBC Disclosure, dozens of families, midwives, and experts have called for urgent action to improve maternity safety in Scotland. They highlighted a pattern of poor—and sometimes deadly—care, often exacerbated by overstretched NHS resources. Families reported feeling shut out by health boards, which they believed were more concerned with reputation than transparency.
Scotland has witnessed increases in Caesarean sections, labor inductions, serious tears during childbirth, and babies born in poorer health in recent years. There have also been spikes in neonatal deaths. Since 2020, there have been 143 Significant Adverse Event Reviews (SAERs) related to maternity care across Scotland, with 44 occurring in NHS Greater Glasgow and Clyde alone. In comparison, England’s Maternity and Newborn Safety Investigations programme completed 613 independent investigations in just one year (2024/25).
One of these Scottish SAERs followed the death of three-day-old Mason Scott McLean in 2023 at Glasgow's Princess Royal Maternity Hospital. His parents, Julie and Angus, noticed Mason was lethargic and uninterested in feeding after returning home. Despite their concerns and Julie’s experience as an NHS intensive care nurse, staff failed to recognize the severity of Mason’s condition. After six hours in the hospital, Mason died from sepsis and related feeding issues. The SAER found that staff recorded his temperature incorrectly, failed to complete his records, and missed key tests that could have indicated a life-threatening infection. Equipment to warm Mason, who had hypothermia, was never sourced. "You just think, are the mistakes going to happen again?" Julie asked the BBC.
Healthcare Improvement Scotland (HIS) began unannounced inspections of maternity units in 2024, with Ninewells Hospital being the first reviewed. Inspectors issued 20 requirements for improvement, citing staffing shortages, delays in care, and missing equipment. NHS Tayside responded, "The HIS report identified areas for learning and improvement and also highlighted where our teams were delivering sensitive, responsive, and high-quality care. NHS Tayside is committed to providing safe, compassionate, and high-quality services to women and families in our care."
Despite these efforts, experts remain concerned that lessons from adverse events are not being fully learned. Dr. Helen Mactier, who authored a recent review of neonatal deaths in Scotland, told the BBC, "It's very concerning that review after review says essentially the same thing. It says that we commonly fail to listen to patients. 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 emphasized that action, rather than more reviews, is needed to address "systemic issues" and improve care.
Public Health and Women's Health Minister Jenni Minto, speaking on October 27, 2025, insisted that Scotland has made "significant progress" in reducing infant mortality, neonatal deaths, and stillbirths over the last 20 years. She stated, "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." Minto also welcomed the new independent inspections of all obstetric units and pointed to initiatives such as safe staffing legislation and the allocation of a primary midwife to every pregnant woman as steps toward raising standards.
Yet for families like the Quates and the McLeans, these assurances are cold comfort. The pain of their loss is compounded by the sense that critical mistakes were made—and that the system still struggles to learn from them. As Scotland continues to review and reform its maternity services, the hope is that these tragedies will finally lead to real, lasting change, ensuring that every mother and baby receives the safe, transparent, and compassionate care they deserve.
