Nottingham University Hospitals NHS Trust | Bolt Burdon Kemp Nottingham University Hospitals NHS Trust | Bolt Burdon Kemp

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Nottingham University Hospitals NHS Trust

Maternity services at Nottingham University Hospitals NHS Trust have been downgraded to inadequate following a recent unannounced inspection from the Care Quality Commission (‘CQC’).  This comes following an Inquest into the tragic death of Wynter Andrews minutes after she was born.  The Coroner at the Inquest found that there was an ‘unsafe culture’ in one of the Trust’s maternity units.

The CQC has now taken enforcement action and imposed conditions on the Trust issuing it with a formal warning notice following the findings in their report.

CQC Report Findings

Inspectors found the following problems that led them to conclude that the maternity services at the Trust were inadequate:

  • Women were being left at risk of harm due to a shortage of midwives and failings by staff to properly assess women who could be high risk pregnancies or at risk of deteriorating on the ward while in labour;
  • There were not 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;
  • Incidents were not always reported due to the demand on staff and there was ineffective feedback and escalation;
  • There was not enough suitable equipment available to help staff safely care for women and babies;
  • Staff did not always risk assess women appropriately and in line with national and local guidance and records were not always maintained;
  • Staffing shortages were noted and staffing levels were not adjusted to ensure safe numbers of staff in all areas;
  • Staff reported that they were frequently missing breaks and working over their hours as a result of the low staffing levels;
  • The service did not have an open culture were staff felt confident raising concerns without fear;
  • Poor leadership was noted, with a culture of not learning lessons and a lack of leadership skills and abilities to effectively lead the service; and
  • Leaders did not operate an effective governance process to continually improve the quality of the service and safeguard the standards of care

What more should be done?

It is terrible news that there is another Trust with inadequate maternity care.  There are clearly deep issues in maternity care throughout the NHS at a national level.  Recently there have been noted issues at Basildon University Hospital Maternity Unit, East Kent Hospitals and even a criminal inquiry launched into Shrewsbury and Telford Hospital NHS Maternity scandal.  It is so frustrating and upsetting to see the same mistakes being repeated throughout the NHS time and time again.

The CQC’s report finding are deeply concerning.  It is so important that lessons are learned.  It is not acceptable that the same mistakes are made time and time again.  The Government have announced that they will investigate the safety of maternity services through the Health and Social Care Select Committee with a focus on why these incidents keep re-occurring and what needs to be done to improve safety.  I hope that this investigation at national level will mean that valuable lessons are finally learned and implemented across the NHS so that we see the end of these reports and tragic events.

It is so important not to forget the real life struggles and tragedies at the heart of these headlines.  Failings such as those noted in the latest report can lead to devastating, life changing injuries or the avoidable deaths of mothers and babies.  There is a huge, irrevocable impact on the mothers, children and families involved.  Any family impacted by the findings of the report deserve answers and urgent changes across the NHS are needed.  Women and families must be assured that they and their babies will be kept safe during pregnancy and childbirth.

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