Inconsistent leadership undermining safety of maternity services, says CQC

In a report published today the Care Quality Commission also said some maternity services need to do more to address unequal outcomes for minority ethnic women, and that not enough learning from good or outstanding-rated services has been shared across systems.

The report draws on the findings from nine maternity safety inspections carried out between March and June 2021.Three of these inspections – at London North West University Healthcare Trust, Sheffield Teaching Hospitals Foundation Trust and University Hospitals of Morecambe Bay FT – resulted in the rating of the maternity services being downgraded to ‘inadequate’.

A further three maternity services – at Salisbury FT, Oxford University Hospitals FT and East Suffolk and North Essex FT– saw their ratings drop to ‘requires improvement’. The rating of West Suffolk FT’s maternity department was unchanged at ‘requires improvement.’

Portsmouth Hospitals University Trust’s maternity service also has a ‘requires improvement’ rating but this was not updated in the latest inspection. Maternity at Sandwell and West Birmingham Hospitals Trust was rated as ‘good,’ despite an independent report finding “weaknesses in culture” at the service. 

CQC’s chief inspector of hospitals Ted Baker said that while many maternity departments provide good care, there has not been enough learning shared from ‘good’ or ‘outstanding’-rated services.

He told HSJ: “This report is based on a small sample of inspections carried out in response to evidence of risk so does not present a national picture. But we cannot ignore the fact that the quality of staff training; poor working relationships between obstetric and midwifery teams, and hospital and community-based midwifery teams, a lack of robust risk assessment, and a failure to engage with and listen to the needs of local women all continue to affect the safety of some hospital maternity services today.

“It is essential that we have a system that is open, and that recognises, investigates, and learns when things go wrong, so that families get the truth, and safety continually improves.”

Inspectors noted a “lack of consistent and clear leadership, management, governance and assurance processes [as well as] the oversight of services and problems in them”. They found the ”variation in the consistency and stability of leadership teams” was affecting staff morale.

The CQC highlighted examples of staff “feeling unsupported or not feeling confident to seek support from senior colleagues or being afraid to challenge decision making,” and “heard many examples of poor incident reporting across the services we visited”.

In 2020, CQC analysis found large disparities in the readmission rates of women who had just given birth. There were 93 readmissions per 1,000 deliveries for black women compared to 68 readmissions per 1,000 deliveries for white mothers.

In June that year the chief midwifery officer Jacqueline Dunkley-Bent wrote to all NHS midwifery services urging them to take four actions to minimise the additional risks faced by women and babies from minority ethnic communities. These included increasing support for at-risk women, using tailored communications, ensuring vitamins and nutrition are discussed at pregnancy and ensuring all providers record the ethnicity of every woman as well as other risk factors.

The majority of the services CQC inspected had worked to implement these four actions, but the watchdog said “in many cases the actions had been interpreted quite narrowly rather than considering what further actions were needed to make services truly equitable and safer for all women.”

Some maternity services which served a mainly white population, viewed engaging with women from minority groups a “low priority,” the CQC said. Some inspectors also heard allegations of discriminatory behaviour from staff towards women who did not speak English.

HSJ approached all the trusts inspected for further comment.

Oxford University Hospitals referred HSJ to a statement made by Bruno Holthof, chief executive officer of Oxford University Hospitals, at the beginning of September. He said: “The trust board is working with the senior management team in our maternity services to develop a comprehensive action plan to address these areas for improvement and concerns.”

A West Suffolk Foundation Trust spokesman said: “The CQC’s focused inspection recognised the progress our maternity teams have made, and we are pleased to see some of the positive aspects they found reflected in this wider system report as examples of good practice.

“We accept though that our maternity service still has improvements to make and our staff are working hard towards this with the CQC, our local Maternity Voices Partnership, and maternity and neonatal colleagues regionally.”

Giles Thorpe, chief murse of East Suffolk and North Essex FT, said the trust has improved ”our staffing levels, leadership and processes” since the CQC inspection. He added: “We have invested in recruitment too and we are pleased that we have a new director of midwifery in post to lead our service, with an additional 30 midwives due to join us by the end of the year to care for expectant parents and their babies.”

Aaron Cummins, chief executive of University Hospitals of Morecambe Bay FT, said in August: ”The safety of our patients and staff is our absolute priority and we have already started making improvements to address the concerns raised, including creating dedicated stroke beds in our hospitals; appointing more colleagues in emergency care and launching new electronic patient record systems in maternity.”

An NHS England spokeswoman said: “The NHS is committed to providing safe, compassionate maternity services, and has invested an additional £95 million into workforce numbers and training programmes to improve leadership.

“We continue to tackle poorer outcomes including by introducing our new equality strategy and fast-tracking our continuity of carer programme, which is proven to significantly improve their overall experience of care.”

Updated at 10am, 21 September to include comment from NHS England, East Suffolk and North Essex FT and University Hospitals of Morecambe Bay FT.