Repeated maternity failings at one of England’s largest hospital trusts

The Care Quality Commission said it had concerns about the care of mothers and babies at Sheffield Teaching Hospitals NHS Foundation Trust.

04 April 2022

Hospital inspectors have found repeated maternity failings at one of England’s largest NHS trusts and expressed serious concern about the safety of mothers and babies.

The Care Quality Commission (CQC) said Sheffield Teaching Hospitals NHS Foundation Trust had failed to make the required improvements to services when it visited in October and November, despite receiving previous CQC warnings.

As well as concerns across the wider trust, a focused inspection on maternity found deep worries about the way its services are run.

The service did not have enough midwifery staff with the “right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment”, the CQC said.

When it came to medical staff, the CQC also ruled the “service did not have enough medical staff with the right qualifications, skills, and experience to keep women and babies safe from avoidable harm and to provide the right care and treatment”.

The CQC previously identified significant patient safety concerns in March 2021, which saw the rating of the maternity service deteriorate to inadequate, but said its reinspection found “there was little or no improvement to the quality of care patients received… in some areas the service had deteriorated further”.

It added it had “significant concerns about the assessment of patients in the labour ward assessment unit, maternity staffing and delays in induction of labour”.

Inspectors found that staff were not interpreting, classifying or escalating cardiotocography (CTG) measures properly, which measure a baby’s heart rate.

A similar concern was raised by Donna Ockenden in her review of Shrewsbury and Telford NHS trust – the UK’s biggest maternity scandal which saw more than 200 baby deaths.

The CQC said that in its reinspection of Sheffield, from October 5 to November 11, documentation on CTG was poor and not in line with national guidelines.

Despite foetal monitoring being highlighted as an area needing attention in 2015 and 2021, the most recent inspection “highlighted that the service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm”.

The report added: “We were informed by staff that there were often difficulties requesting additional assistance when women’s health was deteriorating.

“Staff told us that there were occasions when they would ‘bleep’ for medical assistance on more than one occasion before assistance arriving.

“We were also told on multiple occasions that there were instances where an emergency call buzzer would be pulled after receiving no response to multiple bleep calls.”

There were also inadequate risk assessments which meant “shift changes and handovers did not always include all necessary key information to keep women and their babies safe”.

The CQC’s analysis of data from April to October 2021 showed a “total of 35 patient safety incidents had been raised due to lack of suitably trained/skilled staff”.

One employee told the CQC there were “very unsafe staffing levels on labour ward”, while foetal monitoring was not always completed on time and drugs and observations were late.

Staff also did “not always keep detailed records of women’s care and treatment”, the CQC said, while inadequate grading of incidents causing harm meant inspectors were “were not assured that patient outcomes and the grading of incidents matched the impact or potential impact of harm to the patient or staff member”.

The report added: “After speaking with staff, we were aware of two further serious incident that could not be found on the NRLS (National Reporting and Learning System (NRLS) system.

“Therefore, we did not have assurance that all incidents or serious incidents were investigated, the root cause identified, and that lessons were learnt.”

When it came to pain relief in labour, inspectors said staff “did not always assess and monitor women regularly to see if they were in pain or give pain relief in a timely way”.

Furthermore, staff did not always treat women with compassion and kindness, respect their privacy and dignity, or take account of their individual needs.

On governance and leadership, the CQC said: “We were not assured that leaders had the skills and abilities to run the service. We were concerned that leaders within the service were not effective in implementing meaningful changes that improved safety.”

Trust bosses said they were “devastated” by the findings, vowed to make changes, and said 500 more nurses have now been recruited.

The trust’s overall rating has been downgraded from good to requires improvement.

Its chief executive Kirsten Major said she will do everything she can to support staff to make the necessary improvements.

She said: “We are all devastated with the outcome of the inspection because there is not one person within the trust who does not want to do the right thing for our patients and has not worked hard to try and deliver that in exceptional circumstances.

“That is why we are taking it extremely seriously and I will be doing everything in my power to support our staff and make the improvements we need to deliver.

“We have already taken action that will help us improve, including recruiting over 500 new nurses who are now working on the wards, and there have been changes to our maternity services including investing in more midwives.”

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