Inspectors have found “serious problems remain” at maternity units in Nottingham that are at the centre of a review into dozens of baby deaths and injuries.
The healthcare regulator for England has given a safety warning to Nottingham university hospitals NHS trust and said it must make “significant and immediate improvements” to its maternity services.
The Care Quality Commission (CQC) published details of unannounced inspections it carried out at the trust in March. It said overall maternity services at the two sites remained inadequate and issued the warning notice, with the potential to use enforcement action, in relation to how the trust is managing observations of women, with basic checks not being carried out that would tell if a female patient was deteriorating.
Its report came as Donna Ockenden, the senior midwife who investigated the Shrewsbury and Telford maternity scandal, was announced as the new chair of the review into failings at the trust, after a campaign by families.
The review into maternity services, which had been branded “not fit for purpose” by affected families, will conclude on 10 June.
Ockenden said she was delighted to have been asked to chair the review and would be “engaging with families shortly as my first priority”.
About 450 families have come forward as part of the inquiry into maternity services at the trust, which runs Nottingham city hospital and Queen’s medical centre (QMC), launched amid concerns over the deaths of 30 babies.
Julie Dent, a former NHS trust chair, was originally appointed to lead the review but stood down within weeks for “personal reasons”.
Ockenden led the review of maternity failings at Shrewsbury and Telford hospital trust, which was published in March and found 201 babies could have survived with better care.
In a letter to families on Thursday, NHS England’s chief operating officer, David Sloman, apologised for the “distress” caused by the delay in announcing the new chair.
“After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current review is not fit for purpose, we have taken the decision to ask the current review team to conclude all of their work by Friday 10 June,” he said.
“We will be asking the new national review team to begin afresh, drawing a line under the work undertaken to date by the current local review team.”
The CQC concluded that while staff tried to provide good care, “the service did not have enough staff to care for women and keep them safe. Not all staff had training in key skills.
“Staff did not always assess all risks to women, and we were not assured staff acted upon concerns in a timely way.”
Across the sites, inspectors found staff did not always keep good care records and did not always manage medicines well. They also did not feel assured that staff reported all incidents and near misses, and workers did not always receive feedback.
Referring to previous inspections, the CQC said improvements were still not being implemented across the trust.
The CQC noted that at Nottingham city hospital there were 19 serious incidents reported by maternity staff between March 2021 and February 2022. In addition, there are currently five Healthcare Safety Investigation Branch inquiries.
Fiona Allinson, the CQC’s director of operations for its Midlands network, said: “It is disappointing that despite several inspections where the CQC has told the trust areas they must improve to keep mums and babies safe, serious problems remain.”
