Mothers and babies are being put at risk at one of England’s largest NHS trusts after hospital inspectors found repeated maternity failings and a lack of properly trained midwifery staff.
The Care Quality Commission (CQC) has told Sheffield Teaching Hospitals NHS Foundation Trust to make “urgent improvements” after discovering it failed to make the required improvements to services when inspectors visited in October and November, despite receiving previous 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”. Staff who have raised concerns have been left demoralised after trust managers failed to listen to them.
The report comes less than a week after a review into the largest maternity scandal in the history of the NHS published its findings. Donna Ockenden, the senior midwife who led the inquiry, said that many of the failures at Shrewsbury and Telford Hospital NHS Trust, which contributed to the deaths of 201 babies and nine mothers, were “not unique”.
Gill Walton, chief executive of the Royal College of Midwives, told i last week that a fall in the number of midwives is making it harder for staff to ensure patient safety.
The CQC previously identified significant patient safety concerns at the Sheffield trust 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”.
Inspectors said they had “significant concerns about the assessment of patients in the labour ward assessment unit, maternity staffing and delays in induction of labour”. They 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 the Ockenden review.
The CQC said that in its reinspection of Sheffield, from 5 October to 11 November, 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 said: “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”.
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Other failings concerned pain relief in labour and that women were not always treated with compassion and kindness, nor did staff respect their privacy and dignity, or take account of their individual needs.
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. 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.”
Four in 10 NHS maternity wards in England are rated inadequate or requires improvement, meaning they do not meet safety standards.
