A report by the Care Quality Commission (CQC) published this week has called for urgent improvements to be made following an inspection of maternity services at Hull University Teaching Hospitals NHS Trust.
It comes following an inspection of the services from March to April this year as part of the CQC’s national maternity inspection programme.
Following the inspection, the overall rating for Hull Royal Infirmary has gone down from ‘requires improvement’ to ‘inadequate’, and overall the Trust is rated as ‘requires improvement’.
What were the findings of the inspection?
Some of the reasons the CQC rated maternity services at Hull Royal Infirmary as ‘inadequate’ were:
- Systems, processes, and risks in the antenatal day unit / triage department were not well managed which led to long delays in women and birthing people being seen and a chaotic environment that was not fit for purpose.
- Staff did not always work well together across the different units of the service for the benefit of women and birthing people and some staff spoke about unkindness between staff.
- Staff did not complete training in areas where there was a known risk, and the service did not have a clear policy that set out training requirements.
- Communication between staff where there was a safeguarding risk was not well embedded.
- Staff did not always risk assess women and birthing people, act on presenting risk in line with national guidance, or handover concerns effectively to ensure appropriate care was provided.
- There was a lack of operational oversight and management of risk. Governance symptoms and processes to assess, monitor and manage risks within maternity services were not robust. Further, actions that the hospital had told the CQC had been taken to mitigate previous concerns following an inspection on 15 March 2023 were not maintained when the CQC returned on 24 April 2023.
- Serious incidents were not always reviewed in a timely manner and lessons were not always learned and embedded from serious incidents and external investigations when there were poor outcomes for women and birthing people, to reduce reoccurrence.
- The service was reactive to concerns and there was a lack of clear strategy to improve the safety and quality of the service.
- Storage of medications was not always secure in some areas.
- The design, use of facilities, premises, and equipment did not always ensure women and birthing people were safe.
- Staff did not always keep detailed records of women and birthing people’s care and treatment. Records were not always clear or up to date.
- The service had issues with recruitment and retention and sickness of staff. Staffing levels did not always match the planned numbers putting the safety of women and birthing people and babies at risk.
- The service did not always make sure staff were competent for their roles.
- The service did not have enough medical staff with the right qualifications, skills, training, and experience to keep women and birthing people and babies safe from avoidable harm and to provide the right care and treatment.
- Some staff did not always feel respected, supported, and valued. Pressures on staffing meant that care was at times task focused rather than patient focused.
Conditions on registration
As a result of the investigation findings, the CQC has imposed urgent conditions on the Trust’s maternity service registration to ensure that rapid improvements are made to keep people safe.
The Trust must:
1. Provide a detailed action plan that includes:
a. How it will ensure patients have an appropriate assessment of their health needs including risk assessments to reflect the care they require.
b. How it will ensure patients are clinically prioritised and their health needs are managed appropriately.
c. Actions taken to address the immediate risk to patients, this should include detailed evidence of how it will achieve, sustain, and monitor this going forward.
d. A detailed plan of how it is routinely monitoring patient harm.
e. Details of the effective systems and processes that are implemented to comply with the conditions to ensure that medical and midwifery staff are suitably qualified, skilled, and competent to care for and meet the needs of women and babies within all areas of the Maternity Services.
2. Implement an effective risk and governance system.
3. Implement an effective system for managing and responding to patient risk to ensure all mothers and babies who attend at Hull Royal Infirmary are cared for in a safe and effective manner.
Comment
Unfortunately, this type of shocking report into maternity services is happening all too often.
The CQC inspection and report have highlighted a lot of issues here which are clearly a significant concern given the high level of risk to patient safety of mothers, birthing people, and babies.
This is completely unacceptable and in a time where maternity services are under such scrutiny, it is saddening to see another Trust letting their patients down so badly.
Expectant mothers have the right to have the best and happiest experience in pregnancy, labour, and delivery and as things stand, it seems far from guaranteed that this is what to expect from our maternity services in this country.
Hull University Teaching Hospitals have a lot of work ahead of them to improve their maternity services urgently and given the level of problems, it must be an absolute priority that they deal with this.
How can Nelsons help
Danielle Young is a Legal Director in our Medical Negligence team, which has been ranked in tier one by the independently researched publication, The Legal 500.
If you have any questions in relation to the subjects discussed in this article, then please get in touch with Danielle or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online form.
Contact us