CQC found emergency caesarean taking place without basic safety measures

The Care Quality Commission’s unannounced inspection of Princess Alexandra Hospital Trust last month found an “emergency c-section was being performed without the correct equipment available to monitor the mother”.

A letter said: “Specifically, the [electrocardiography] machine [which checks for abnormal heart rates] was not available, and this had not been checked after the previous procedure.”

The CQC inspectors stepped in immediately to “escalate concerns” about this safety breach. The trust then rectified the situation straight away.

An official investigation report has not yet been published but the incident was highlighted in a letter from the watchdog, which was in the papers for the trust’s board meeting this month. 

PAHT’s board meeting confirmed six other maternity serious incidents were also being investigated. This includes a “significant” post-partum haemorrhage, which it said resulted from “human factors” rather than staffing levels. Sharon McNally, director of nursing, midwifery and allied health professionals at the trust told HSJ: “The mother and baby involved were both well following the incident and we have implemented changes already identified through our internal investigation, as we want to ensure we always learn from an incident, however rare.”

The papers said there had been “11 overarching maternity serious incidents since April 2020 and six of those remained open. Some of the SIs open since the end of the previous year related to the cluster of [10] from October/November 2020.”

The papers said these incidents included:

• “Reduced foetal movements/management of fetal growth”, leading to the death of the baby in the womb;
• “A massive obstetric haemorrhage”, with concerns raised over “possible delay of transfer and blood products”; and
• A scalp laceration incurred during an emergency caesarean section.

The CQC visit also found concerns with the maternity service’s staffing, including “excessive use of locums and changes to the rota including cancellation of leave”. Maternity staff reported “being burnt out… and sometimes working without safe staff numbers”.

The regulator said problems with locums not receiving appropriate inductions was “particularly concerning” as they had been involved in two serious incidents during 2021.

The letter to the trust said: “Overall, we were concerned that the safety culture in the service was underdeveloped. There were no dedicated maternity safety huddles in line with national guidance. Handovers doubled up as safety huddles. During our observations of handovers, we saw that staff did not discuss safety issues and the format was not safety focused.”

Trust chief executive Lance McCarthy responded in writing to the concerns raised by the CQC, which was also included in the August board papers. He said a new business case for two additional maternity consultants and five registrars had been approved, with new staff likely to start from September 2021.

A new patient safety strategy is also due to launch in September, which he said would improve how learning is shared across the trust in a “sustained way”. External psychological and wellbeing support for maternity staff had also been initiated. He added four times a day safety huddles had now started.

The maternity unit was last rated in July 2019, when it dropped two ratings from “outstanding” to “requires improvement”. A rating from last month’s inspection has not yet been issued.

The maternity inspection formed part of a full inspection in PAHT’s services, which started on 7 July. The regulator has also raised concerns about the ongoing management of patients’ fall risk on one ward. In response, the trust completed a review of all the ward’s patients.

The trust is currently rated “requires improvement” overall. 

Ms McNally also told HSJ: “The safety of every mother and baby is our priority, and we have improved our triage process that assesses women in our care, we are reviewing and improving our induction and supervision programmes and are recruiting additional staff to help make sure our unit delivers the best possible care.”

Updated at 9.43am 9 August 2021 to include comment from the trust.