Hospital inspectors have uncovered repeated maternity failings and expressed serious concern about the safety of mothers and babies in Sheffield just days after a damning report warned there had been hundreds of avoidable baby deaths in Shrewsbury.
The Care Quality Commission (CQC) found Sheffield teaching hospitals NHS foundation trust, one of the largest NHS trusts in England, had failed to make the required improvements to services when it visited in October and November, despite receiving previous warnings from the watchdog.
As well as concerns across the wider trust, a focused inspection on maternity raised significant issues about the way its service is run. When it came to medical staff at the Sheffield trust, 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 report said.
It comes less than a week after the Ockenden report on the UK’s biggest maternity scandal at Shrewsbury and Telford hospital NHS trust concluded that 201 babies and nine mothers could have or would have survived if an NHS trust had provided better care. Police are examining more than 600 cases linked to the scandal, the Guardian reported last week.
The CQC previously identified significant patient safety concerns in Sheffield in March 2021, which led to the rating of the maternity service deteriorating to inadequate. Its reinspection, it said, found “there was little or no improvement to the quality of care patients received … in some areas the service had deteriorated further”. It also had “significant concerns about the assessment of patients in the labour ward assessment unit, maternity staffing and delays in induction of labour”, it added.
Inspectors found that staff were not interpreting, classifying or escalating measures of a baby’s heart rate properly, an issue that was raised by Donna Ockenden in her review of the Shrewsbury scandal.
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.”
The CQC was told there were “very unsafe staffing levels on labour ward”, while foetal monitoring was not always completed on time and drugs and observations were late. The CQC also said it was concerned that not all incidents or serious incidents were investigated, the root cause identified, or that lessons were learned. Precisely the same concern was raised in Shrewsbury.
The trust’s overall rating has been downgraded from “good” to “requires improvement”. Its chief executive, Kirsten Major, said she was “devastated” by the findings, and took them “extremely seriously”. She added: “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.”
