• Maternity and surgery departments criticised at Royal Cornwall Hospitals Trust
  • Trust told to make “significant improvements” by 13 April
  • CQC made unannounced inspection in January

Patient safety is not prioritised enough at a special measures trust’s maternity and surgery units, the chief inspector of hospitals has warned.

Professor Ted Baker said he was “disappointed” longstanding concerns persist about the safety and quality of some services at Royal Cornwall Hospitals Trust, following an unannounced Care Quality Commission inspection in January.

The trust has been ordered to make “significant improvements” by 13 April in a section 29A warning notice.

Royal Cornwall was placed in special measures in October after the CQC found evidence suggesting two patients had died due to a backlog of follow-up appointments in cardiology; safety concerns in the maternity department; poor reporting and investigation of serious incidents; and allegations of bullying.

Inspectors returned in January to check on progress in the areas of greatest concern.

Professor Baker said the trust had improved within cardiology and ophthalmology, and services for children and young people.

But he warned that in “all other areas” work is needed to meet the requirements of the warning notice.

Trust chief executive Kathy Byrne said: “We are working on every area required to ensure we succeed in getting the trust taken out of quality special measures as soon as possible.”

The CQC found several shortcomings in maternity services. These included:

  • Not all women booked for a home birth had home visits or risk assessments carried out at 36 weeks of pregnancy.
  • An obstetric theatre in a 50 year old building was not meeting standards for its preparation space, floor area, recovery facilities and air change rate.
  • There was no process to ensure community midwives always had the correct equipment for use in emergencies while waiting to transfer a patient to hospital.
  • Systems and processes for managing deteriorating women were “ineffective”.

The CQC also said the trust was failing to comply with the requirements for duty of candour.

It was concerned work to clear the trust’s backlog of serious incident investigations would not be sustained.

The trust’s clinical lead for serious incidents was given three hours a week to carry out their role but two of these were spent in a weekly meeting and the third was spent preparing for this meeting, the CQC said.

Royal Cornwall has been identified as an outlier of never events by the CQC and inspectors were made aware of three cases that may have met this criteria but had not been reported.

“This raised concerns about the timeliness of investigating and reporting, and the culture of waiting to report, rather than reporting and downgrading the incident where relevant,” the report said.

The CQC highlighted six cancelled cancer operations between October and January. On average, the patients were treated 19 days later.

The trust had ended its backlog of unreviewed echo and cardiac event recordings and most were now reviewed within four weeks – two weeks quicker than the national average.