Maternity services at one of England’s largest hospital trusts have been downgraded to inadequate over safety fears by the care watchdog the Care Quality Commission.
The regulator has taken enforcement action against Nottingham University Hospitals Trust, including imposing conditions on the trust and issuing it with a formal warning notice.
Inspectors found women were being left at risk of harm because of a shortage of midwives, and failures by staff to properly assess women who could be high-risk pregnancies or at risk of deteriorating on the wards while in labour.
The trust, which delivered 8,200 babies in 2019, has been criticised by families who have demanded an inquiry into maternity care at the trust after an inquest in October heard hospital staff had written to the trust board in 2018 warning of safety concerns about maternity services.
The CQC said staffing concerns had been reported as incidents by midwives at the trust’s Queen’s Medical Centre site on 30 occasions between April 2020 and September 2020.
Baby Wynter Andrews died in September last year after being born via a caesarean section following long delays. Her umbilical cord was wrapped around her neck and leg, resulting in her being starved of oxygen.
The coroner, Laurinda Bower, criticised what she said was an “unsafe culture” in the maternity unit and ruled Wynter’s death had been caused by neglect.
Inspectors for the CQC went into the trust’s two maternity units in Nottingham the week after the inquest in a series of unannounced inspections.
In a report of their findings, the regulator said: “The service did not have an open culture where staff felt confident raising concerns without fear.”
On staffing levels it said: “Although managers regularly reviewed staffing levels, they were not always able to adjust staffing levels to ensure safe numbers of staff in all areas due to staffing shortages. Staff said they frequently missed breaks and worked over their hours due to the low staffing levels.
“We were told of occasions when unsafe staffing had been declared and this was challenged, and staff had been asked to change it back to safe by senior managers.”
Inspectors highlighted repeated failures of staff to use cardiotocography (CTG) equipment, which helps to monitor a baby’s heart rate during labour.
The inspectors said: “We saw evidence of multiple occasions when CTG categorisation tools were not used and CTG traces were not categorised correctly. Traces were not always reviewed by a senior member of the medical team when necessary, meaning there were missed opportunities to identify risk to women and babies.”
Inspectors said they were also worried that patient safety incidents were being wrongly downgraded.
The report said there had been 488 incidents reported between July to September 2020. Three of these were classified as severe harm, six as moderate harm, and 477 as low or no harm.
It added: “We observed a number of incidents were inappropriately graded. For example but not limited to; babies transferred to the neonatal intensive care unit were graded as no harm or low harm, a maternal death was graded as low harm and a woman admitted to the intensive care unit was graded as low harm. Therefore, we were not assured that incidents were being graded appropriately. This meant that incidents may not be investigated fully, nor duty of candour applied correctly. People would be at risk of harm as lessons could not be learnt.”
Baby Wynter’s parents, Sarah and Gary Andrews, told The Independent they were “deeply worried” about the CQC’s findings, adding: “There have been consistent concerns raised by the CQC for years and yet the trust have changed little. We are not convinced that the trust is capable of change on their own. They have been given multiple opportunities over the years to make the changes to protect babies and parents and yet we are here.
“We know that Wynter was not an isolated incident. We know there are other families out there who have lost babies because of the systemic failures of the trust.”
They repeated their calls for a public inquiry into what had happened at the trust.
Lawyer Natalie Cosgrove, from Switalskis Solicitors, added: “I am exceptionally concerned about the trusts ability to enact change. During my investigations there are often promises of protocol changes, but protocols do not change the culture. I remain of the view that without a public inquiry and further rigorous review, then I will be representing clients year after year in very similar and sad circumstances. This cannot be right.”
The trust said it had now recruited an extra 17 midwives with 26 new staff planned to start in January. It said it was planning to increase the level of senior staff as well as new training and competency checks as well as staff using new systems to check women’s risks.
CQC’s chief inspector of hospitals, Ted Baker, said: “During our visit to Nottingham University Hospitals NHS Trust’s maternity services, we were disappointed to find some serious concerns which were impacting on women’s care and safety.
“We found fundamental practice, like adequately risk-assessing women and babies, was not always done.
“Women's notes were not comprehensive and not all staff could access them easily. We found that there was a combination of paper and electronic records in use across the unit. The main electronic records system was only accessed by midwives and was not able to be accessed in the community by GPs or community midwives.
“Following the inspection, we placed conditions on the trust’s registration and issued a warning notice to ensure mothers and babies experience the safe, effective and personalised care they are entitled to.”
Tracy Taylor, chief executive at Nottingham University Hospitals said: “We want to provide the best maternity services for local people, and the priority of our maternity team is to provide safe care to the families they come into contact with every day but we know we haven’t always got this right, and we are very sorry.
“We accept the report from the CQC and have already made some immediate changes and will continue to make further improvements, and I would like to reassure local people that we are committed to working to make its maternity service one that we can all be proud of.”