- Report raised serious concerns over consultants’ on-call duties
- CQC aware of report but says it did not receive in full until 2019, three years after it was finished
- Ongoing inquest into baby’s death in 2017 likely to highlight similar problems
The Care Quality Commission has said it only saw a damning report into a series of failings in a trust’s maternity services three years after it was written.
The Royal College of Obstetricians and Gynaecologists report, which was based on interviews in November 2015 and written in early 2016, was commissioned by the medical director of East Kent Hospitals University Foundation Trust over various concerns with the trust’s maternity services. The trust offers maternity services at two sites — the William Harvey Hospital in Ashford and the Queen Elizabeth, the Queen Mother, Hospital in Thanet.
However, despite containing several warnings about the quality of care within the services, the CQC has said it did not receive the report in full until 2019.
In particular, the report highlighted concerns about consultants, and said there was a culture of “failing to challenge these poorly performing consultants”.
Assessors were told consultants were present on the labour ward for 60 or 70 hours a week, with a consultant-led ward round and two reviews of high-risk women daily. Although they concluded this happened at the WHH, records they reviewed did not support that this happened at QEQM.
The report added: “Interviews revealed significant concerns about the failure of three to four consultants on the [QEQM] site to conduct daily labour ward rounds, review women, make plans of care and attend when requested out-of-hours.”
The RCOG’s interviews also revealed concerns that:
- Consultants’ behaviour at meetings at the WHH was “disrespectful”;
- There was poor attendance by consultants at the QEQM, particularly at weekends, which was described by other staff as a “reluctance/refusal to attend out-of-hours”; and
- During an investigation into a consultant’s communication skills and competences, the consultant was “given staff statements and allegedly confronted individual staff” and faced no sanction from the trust for doing so.
The report called on the trust’s medical director to investigate allegations consultants were not complying with their duty of care.
The report also found many major clinical guidelines did not reflect the then current evidence-based practice and the trust had only recently sought evidence of compliance with National Institute for Health and Care Excellence guidelines.
RCOG also found staff felt maternity services were not “on the priority list at board level” and the former chief executive was disengaged on this. Medical and midwifery staff felt there was no point in reporting safety issues as the trust would not take action.
However, a CQC spokesperson said, although it was made aware of the report being commissioned and the trust had shared information about what it was doing in response to the findings prior to a September 2016 inspection, ”our records do not indicate that we received the full report before January 2019”.
The trust’s maternity services were rated “requires improvement” following the 2016 inspection. That rating remained unchanged following a 2018 inspection, although the spokesperson said inspectors “noted that the department had changed its approach to foetal monitoring training after concerns were identified”.
The spokesperson added: “The trust remains subject to close monitoring and further inspections.”
Changes at the trust
In a statement, the trust said it began an improvement programme after it received the report in February 2016, reporting its progress to the CQC as part of this. Changes made include:
- Improving team working between professional groups;
- Updating clinical guidelines and introducing a maternity ‘dashboard’ for quality indicators;
- Adding two substantive consultant posts and revising job plans for some consultants;
- Auditing consultant attendance at labour ward handover, and board and ward round meetings;
- Investing in new CTG and ECG machines, cardiac monitors and neonatal resuscitaires;
- Introducing a training programme aimed at developing a continuous learning culture;
- Revising policy for recruiting and supervising locum and junior doctors;
- Updating guidance on escalation to consultants on call; and
- Introducing more comprehensive monitoring of foetal heart rates during labour.
Many of the issues the report raised have been echoed in an ongoing inquest into the death of Harry Richford, who died a week after he was delivered at the QEQM in November 2017.
The inquest, which is due to conclude this week, has been told of “panic” after Harry was born by emergency Caesarean section, after a long labour in which his heartbeat kept dropping; of disagreement over whether his mother should be given a drug during labour; about an independent report that he might have survived had there not been a delay in resuscitation; and of poor notetaking by one doctor.
The trust has already apologised and said his care “fell short of the standard that we expected to offer”.
The report looked at seven “index cases” — two of which involved the deaths of babies — where serious incident reviews had been carried out. It also examined 16 further cases, including some where mothers developed severe pre-eclampsia — which can develop into a life-threatening condition — or had massive bleeds after birth. The cases were at both the QEQM and the WHH.
Issues identified include:
- Guidelines for prescribing were not followed when midwives used a drug to speed up labour without it being prescribed by a doctor. The reviewers said this practice was “unacceptable and potentially dangerous”;
- In one case, a senior house officer viewed a cardiotocography trace of a baby’s heartbeat at 17:30 and suggested review in 20 minutes. A review did not happen until 20:44, by which time the baby needed an instrumental delivery and had a pneumothorax;
- Delays in performing a Caesarean section after a decision was made to operate meant a baby was probably born in poorer condition, while the registrar involved “failed in their duty of care to ensure the baby was delivered within the 30 mins recommended interval”;
- A woman collapsed after delivery and required CPR, but the collapse was precipitated by a failure to give her fluids before a spinal anaesthetic, despite significant blood loss;
- A woman who had been admitted as an emergency mid-pregnancy was only reviewed by an SHO for 20 hours, at which point a consultant saw her after a midwife became concerned about her deteriorating condition. A required standard of NHS care is emergency admissions should be seen by a consultant as soon as possible, and at least within 14 hours;
- Consultant involvement “could not be identified” in a high-risk twin pregnancy where the woman developed severe pre-eclampsia. In another case, there was “no evidence of regular consultant ward rounds or involvement” before a woman who had been admitted to the QEQM with severe pre-eclampsia was transferred; and
- In seven cases of post-partum haemorrhage, there were “delays in escalation from the midwifery team to doctors and from midwives/middle grades to consultants.” In one case, a woman lost 3.2 litres of blood but there was no evidence of consultant involvement or a consultant ward round until she was in theatre. In other cases, junior doctors managed blood losses of 2.5 litres without consultant presence.
CQC and trust statements, RCOG report
January 2020, RCOG report 2016