Hull Royal Infirmary maternity service failing its legal obligations

Hull Royal Infirmary (HRI) maternity service is not safe or well-led.  This is the conclusion of the Care Quality Commission’s report into maternity services at Hull Royal Infirmary, run by Hull University Teaching Hospitals NHS Trust following inspections in March and April this year. The report makes for exceedingly grim reading, not least because we’ve already seen so many of the inadequacies that are highlighted at Hull in previous CQC reports of other maternity services, at Shrewsbury and Telford Hospital NHS Trust, Nottingham University Hospitals NHS Trust, East Kent Hospitals NHS Foundation Trust to name but a few.

Hull Royal Infirmary maternity service is now rated inadequate, the lowest rating possible, and described as having a chaotic, unsafe environment, and being unfit for purpose.  Overall, the inspection report highlights inadequate leadership, a lack of vision and strategy, and cultural issues, issues with staffing, patient focus, health inequalities, complaints management, governance, and oversight. It identifies significant deficiencies in management, training, and communication, deficiencies in medical staffing, medicines management, and incident management. It reports issues with leadership awareness and action, governance meetings, policies and guidance, and performance management.

Of most concern to me as partner in the Child Brain Injury Team at Bolt Burdon Kemp are the inadequacies and failures in care that lead directly to devastating brain injuries that cause life-long disabilities, pain and suffering for the babies that are my clients, and that are completely avoidable.

Inadequacies such as:

• Long delays and a chaotic environment in the antenatal day unit/triage department, due to poorly managed systems, processes, and risk.
• Staffing issues, high workload, and limited capacity.
• Missed opportunities to identify babies who were small for gestational age.
• Incomplete mandatory training.
• Inadequate induction, training, support, supervision and oversight that women and babies are at risk.
• Unsuitable and unsafe facilities, impeding effective monitoring and oversight of patients.
• Lack of suitable equipment and emergency plans, such as the absence of a neonatal resuscitaire in the antenatal day unit.
• Failure to complete risk assessments and respond to patient risks in a timely manner.
• Failure to monitor waiting times and midwifery reviews, resulting in delays and lack of medical support.
• Inadequate telephone triage system, with a lack of structure, guidance, and oversight.
• Inadequate shift changes and handovers with poor communication, compromising patient safety and continuity of care.
• Lack of CTG monitoring.
• Inconsistent use of nationally recognised tools, such as the Modified Early Obstetric Warning Score (MEOWS), to identify and escalate concerns about women and birthing people at risk of deterioration.
• Lack of written information in different languages about high-risk areas, such as reduced foetal movement.
• Incomplete and out of date records of women’s care and treatment, putting women and babies at risk.
• Inconsistent recording of calls made to the maternity service, leading to information not being shared or followed up on when necessary.

In short, staff fail – or perhaps more accurately, are unable – to provide the required standard of care due to a lack of effective systems, processes, and staffing. The same failings have been identified in previous investigations, but no action has been taken to address these repeated issues and so it is strange that despite this history, Hull Royal Infirmary is not listed on the NHS England website as being on the National Maternity Safety Support Programme (MSSP).  Maternity services are formally entered onto the programme if they are rated “requires improvement” or “inadequate” in the well led and/or the safe domains by the Care Quality Commission, as HRI is.

What must HRI maternity service now do?

Hull maternity service must now take action to comply with its legal obligations.  They have to do certain things required by regulations to prevent future non-compliance and improve services.

They MUST:

• Ensure there are thorough risk assessments for women and birthing people, following national guidance to address any identified risks.
• Establish a safe handover process when women and birthing people move between units to ensure their health and safety.
• Keep staff up to date with mandatory maternity training modules.
• Provide regular skills and drills training, including pool evacuations.
• Implement systems and processes to assess, monitor, and improve the quality and safety of the service.
• Assess, monitor, and mitigate risks related to the health, safety, and welfare of women and birthing people.
• Maintain accurate and complete records for each woman and birthing person.
• Review medical staffing for maternity ADU/triage to ensure enough qualified staff in line with national guidance.
• Provide staff with appropriate safeguarding supervision and support.

The service should also:

• Review accidents and incidents to identify potential health inequalities for those involved.
• Consider the availability of food and drinks in inpatient areas to ensure independent access for women, birthing people, and their families.
• Implement a training policy and procedure that addresses the needs of the staff and addresses any current shortcomings.

Red Flag Events not reported

One shocking fact to emerge from the report is that not all red flag incidents had been reported across the maternity service but, even so, there were no less than 31 red flag events reported in the six months before the inspections, all of which occurred on the labour ward. Lack of CTG monitoring in one serious incident led to a baby’s tragic death, but this failure in care was not appropriately recognised or shared with the family.  This is nothing less than outrageous.

How can we help?

Our specialist Child Brain Injury team at Bolt Burdon Kemp works with families all over the country to support the families of babies who have suffered serious brain injuries due to poor maternity care. We see all too often the devastating consequences of failing to monitor the foetal heartbeat or failing to interpret CTG or scans correctly due to inadequate training, or lack of equipment and staff.  We act swiftly to put in place the specialist care, equipment, therapy and support needed not only to alleviate the immediate challenges faced by the brain-injured child and their family, but also to contribute to achieving the best possible physical, cognitive, emotional, and social functioning for them. We aim to maximise the child’s potential for recovery, independence, and quality of life. This may include improvements in motor skills, communication abilities, cognitive abilities, and overall well-being. We provide support and resources to the child’s family, helping them navigate the challenges and emotional impact of caring for a brain-injured child. This may involve providing access to therapy, counselling, education, and financial assistance to alleviate the burdens and ensure the family’s well-being. Ultimately, we want to help our clients and their families to adapt, cope, and thrive despite the challenges posed by the brain injury. Through the claim, we aim to provide the child with the best opportunities for development and the family with the necessary support to lead fulfilling lives. We strive to recover the maximum compensation to provide for the child’s lifelong and evolving needs so that parents have peace of mind that their child will always be safe and will flourish, no matter what happens to them.

If you’ve been affected by poor maternity care at Hull Royal Infirmary and would like to chat with one of our kind and experienced solicitors, please get in touch with us for a free, no obligation conversation.