Major hospital’s maternity services downgraded to ‘inadequate’ amid fears for mothers and babies

Maternity services at one of England’s biggest hospital trusts has been downgraded from outstanding to inadequate amid fears for the safety of mothers and babies.

The Care Quality Commission has imposed conditions on Sheffield Teaching Hospitals NHS Foundation Trust after an unannounced inspection in March warning it was concerned patients could be at risk of harm.

The watchdog found a shortage of midwives on wards and a failure to properly investigate and learn from safety incidents including a failure to report deaths of mothers as a serious incident. The trust had reported five deaths of women between October 2019 and December 2020 but only three were reported as serious incidents and investigated.

The CQC also said equipment was not checked and concerns it had raised in 2015 had still not been acted on.

It said it was worried staff did not have the “skills, competence, knowledge and experience to safely care for women and their babies.”

Some staff did not complete risk assessments women and mothers were not prioritised based on risk but instead on when they turned up to the Jessop Ward, near the trust’s Royal Hallamshire Hospital.

Patient records systems were also not linked up meaning clinicians caring for mothers were not aware of the full clinical picture.

Inspectors rated the service inadequate overall and inadequate for safety and for whether it was well-led – warning it lacked confidence in the management to run the ward effectively.

The CQC said it had imposed conditions on the trust “as we believed a person would or may be exposed to the risk of harm if we had not done so.”

It’s inspection report said that when things had gone wrong “there were concerns that there was a lack of openness and transparency” adding: “We were not assured the leaders had the skills, knowledge and experience to run the service.”

Following a series on investigations into maternity incidents at the trust by the Healthcare Safety Investigation Branch the CQC found midwives, managers and senior leaders “could not articulate any of the themes from the HSIB reports or any actions they had put in place to mitigate the risks of them occurring again.”

On staffing levels, the inspection report said the trust’s chief nurse, nurse director and head of midwifery had not followed recommendations on staffing levels with audits showing the unit was “consistently short”.

In one incident, there was just one midwife and one clinical support worker to look after two women waiting for beds after giving birth, two women who needed advanced obstetric care as well as another woman with a post-birth haemorrhage, a high risk neonatal baby, and a diabetic mother. There was also a woman waiting for a caesarean section.

Sarah Dronsfield, CQC's head of hospital inspection, said: "When we visited maternity services in the Jessop Wing at Sheffield Teaching Hospitals NHS Foundation Trust, inspectors found a service that was not providing the standard of care women should be able to expect.

"Our findings were such that the ratings for maternity services across the trust have moved from outstanding to inadequate."

Ms Dronsfield added that some areas of good practice had been found, such as staff wellbeing, equality and diversity, and that an action plan had been provided.

"We continue to monitor the trust extremely closely and expect them to continue to make rapid improvements," she said.

"The trust leadership team know what they must do to improve patient safety and we will re-inspect to ensure this happens, taking further action if needed to protect patients."

Following the CQC's decision, Sheffield Teaching Hospitals' chief executive and chief nurse assured women coming to the Jessop Wing that they would be safe.

It told The Independent it had recruited an extra 30 midwives since the CQC inspection. These staff will join in September alongside 14 midwifery support workers and 11 trainees.

The trust emphasised the inspection was only of maternity care services and did not cover the neonatal unit, gynaecology, or fertility services.

Kirsten Major, chief executive of the trust, said: "Our maternity teams work incredibly hard every day to ensure their care is always the number one priority.

"Whilst we are exceptionally disappointed with the findings of the CQC report, we welcome the external scrutiny and have wasted no time in responding to the actions which have been identified as necessary.

"Many of the actions have been completed in the three months since the inspection took place."

Professor Chris Morley, chief nurse at the trust, said: "The teams in the Jessop Wing are responding to this report with the commitment and professionalism we see every day and are completely focused on continuing to deliver safe, good care to women and their babies.

"If any women or their partners have concerns following this inspection, then please do not hesitate to contact us and the team will be happy to provide assurance.”