The investigation found the unit was significantly understaffed, at one stage by more than 17 whole-time equivalent midwives.
The watchdog also found that demand at the QEUH maternity unit frequently exceeded planned capacity, with induction and caesarean lists regularly going beyond available slots.
Concerns about how whistleblowers were treated were also upheld.
The QEUH is one of the largest hospitals in the UK and has been at the centre of a long-running patient safety controversy linked to its design and construction.
The hospital is currently subject to a national public inquiry following a series of deaths and infections associated with its water and ventilation systems, including issues on high-risk wards such as bone marrow transplant units.
Earlier this month, The Herald launched a major investigative series examining pressures on maternity services across Scotland, highlighting growing concerns about safety, staffing and the resilience of care.
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INWO’s investigation was triggered after a number of complaints about staffing levels, workloads and delays to access the maternity unit’s labour ward.
Concerns were first raised about patients and staff safety in the maternity unit with the board in June 2024. NHSGGC’s investigation finished three months later and partially upheld most of the concerns, making a number of recommendations.
But when the board failed to meet deadlines to implement these recommendations, the whistleblowers contacted the watchdog.
The investigation found that the health board had clear evidence of staffing shortages in the maternity unit for at least 18 months.
Formal assessments in 2023 and 2024 identified significant shortfalls in midwifery numbers. However, the board did not have a system in place to turn those findings into actually hiring more staff.
The INWO found this gap persisted well after new legal duties on safe staffing came into force in April 2024, concluding it was “unreasonable” that no system was in place to act on the data.
The watchdog said this had “a significant impact” on the whistleblowers and their trust in the Board.
“Short staffing and high workload impacted on staff retention and sickness. It also reduced the quality of care for patients on some occasions, which will have had consequences for their physical and mental health too. ”
There were reports of midwives being unable to take breaks and becoming physically exhausted.
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Last November, the Board told INWO that staffing “remains a critical risk”.
These shortfalls were compounded by a number of other pressures.
While the overall number of births has not significantly increased, the report highlights a growing number of patients with conditions such as obesity, diabetes and cardiac issues, requiring more intensive care.
There has also been a rise in planned caesarean sections and inductions of labour, with caesareans exceeding vaginal births for the first time in 2024.
At the same time, capacity planning remained largely based on a 2014 staffing model, despite the hospital taking on a specialist national role for premature and complex births.
Attempts to manage demand — including sending patients to other hospitals and introducing new triage and induction processes — were implemented, but often at an early stage or without sufficient staffing to support them.
The pressures led to significant delays.
Patients in the unit were “regularly waiting between 48 and 72 hours” to access the ward for induction of labour.
Staff warned that such delays carried clinical risks, including “sepsis and more complicated births”, and said that where capacity pressures forced women to give birth outside the labour ward, other areas were “not equipped to provide some types of pain relief or deal with complications like haemorrhages”.
The watchdog also found a lack of clarity around responsibility for decision-making.
Senior midwives were frequently left to prioritise patients for labour ward access and theatre capacity.
While the board maintained that decisions were shared with obstetric colleagues, staff told the investigation that, in practice, midwives felt they were carrying the clinical and professional risk alone.
The report also highlights failures in the whistleblowing process itself with governance arrangements not robust enough to ensure recommendations were delivered, and that communication with whistleblowers about progress was inadequate.
This, the report says, undermined confidence in the process and created a perception that concerns were not being taken seriously.
The Herald understands a Healthcare Improvement Scotland report on the maternity unit is expected shortly.
Scottish Conservative MSP for Glasgow Annie Wells said: “This damning report must result in urgent improvements to maternity services at Scotland’s flagship hospital.
“It is scandalous that any pregnant woman could have been left for days to access labour wards which were also dangerously understaffed.
“These findings should be a source of shame for health board bosses and SNP ministers. They point to a culture of secrecy and trying to sweep serious concerns about patient safety under the carpet.”
Scottish Labour health spokesperson Dame Jackie Baillie said: “This is a damning and deeply worrying report into maternity services at the Queen Elizabeth University Hospital.
“This independent report has upheld a number of troubling complaints relating to NHSGGC, including that it did not ensure appropriate staffing levels in the QEUH maternity unit, did not appropriately manage patient demand, and did not ensure there was appropriate out of hours service arrangements.
“Concerningly, the investigation also found that the board did not handle whistleblowing concerns in line with national standards. This further underlines the prevailing culture of secrecy and cover-up at the health board and hospital, in which people were bullied and silenced.
“There is a vital and urgent need for NHSGGC to learn from the past and to implement the recommendations made in the report, to improve transparency, and crucially, to ensure patient safety.”
A spokesperson for NHSGGC said: “We fully accept the recommendations of the INWO report and give our commitment to addressing the issues raised.
“The safety, wellbeing and experience of our patients and staff working within our maternity services remain our highest priority and apologise for our previous failures.
“We have started the work required to improve the issues outlined, including the ongoing recruitment of midwives to address the historic workforce pressures. We continue to invest in our midwifery workforce, with 36 additional staff joining NHSGGC over the past year. We are also in the process of recruiting further experienced midwives over the coming year.
“In addition, we have implemented a robust triage to ensure that we are able to effectively and consistently respond to the needs of our patients. We have also appointed a dedicated clinical skills midwife, and later this year we will welcome our annual intake of newly qualified midwives. We have strengthened our support for these newly qualified staff to ensure they are equipped to play a full part in the NHSGGC team.
“We have listened to the feedback from staff and patients and developed clear improvement plans which are already underway. We want our maternity services to be safe and responsive to the needs of women and families in Greater Glasgow and Clyde, and we have introduced a range of measures to support our staff and improve patient care.
“We are committed to ensuring that all staff who raise concerns are treated with respect, supported appropriately, and kept informed throughout the process.
“NHSGGC has undertaken a review of our whistleblowing processes to ensure alignment with national whistleblowing standards. We are also continuing our work to improve our Speak Up culture to ensure all staff have the confidence to raise concerns. ”
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