Mothers and babies are being put at risk in an NHS unit where a senior doctor has been censored after raising the alarm over changes that are leaving wards dangerously understaffed, The Independent can reveal.
Insiders at the Worcester Royal Hospital have described women with high-risk pregnancies experiencing long delays to give birth after being induced, some for up to five days, while other women, who can sometimes be lower risk, are jumping the queue and being seen ahead of them.
Other women in need of urgent caesarean sections have also been made to wait while women with a planned, or elective, caesarean have been seen first.
Four women have died at the Worcestershire Acute Trust between July 2019 and December last year, with midwives telling The Independent they are working in fear of what might happen during their shifts.
The maternity department’s clinical director resigned from her role earlier this month and in a damning internal message, leaked to The Independent, she criticised senior bosses at the trust for censoring her for speaking out about the “gridlocked system” and “unacceptably long delays” for some women.
Consultant obstetrician Catherine Hillman said her role as clinical director was no longer tenable after a message she posted was taken down on the instruction of managers. She said the maternity unit was “at best precariously safe” and that she now realised it was “heresy to question the safety and validity of the situation and I am unable to continue to hold this party line.”
The problem has been linked to the introduction of a new model of care for women known as “continuity of carer”, where women see the same midwife throughout their pregnancy, with the midwives on call for when they go into labour.
This is being rolled out by NHS England to hospitals across England this year, with all women to be offered the service by 2023.
To create the dedicated teams, bosses at Worcester pulled midwives from its core staff, leaving the hospital unit without enough specially trained staff. The new service has been gradually increased since starting in 2019, with six teams and a total of 36 midwives on the new system.
Whistleblowers say this means women on the wards have fewer midwives to look after them and they can be short of five or six midwives per shift. Meanwhile, women with a continuity midwife, who are often lower risk, are jumping ahead to deliver their babies because their midwife is available straight away.
Internal audits show the maternity unit at Worcester was short staffed on its delivery suite for almost half of all shifts between July and December last year. The trust said similar shortages had been reported between January and April but its staff were redeployed to fill gaps when needed.
Jane Sandall, professor of women’s health at King’s College London, who has researched the continuity of carer model told The Independent that hospitals needed to be careful with its implementation.
She said: “All women should be prioritised according to need for escalation and ongoing treatment according to national and trust guidance, and whether they are in a continuity of carer model or not should make no difference to how this is managed by a trust. I don’t understand why this was allowed to happen.”
She added: “It can be implemented really badly, or it can be implemented really well. It shouldn’t introduce inequity. It was never the intention to focus only on healthy women, that won’t deliver the benefits.
‘I cannot in all conscience continue to remain silent’
The problems at the Worcester Royal hit crisis point earlier this month when Dr Hillman posted a message to staff on an internal Facebook page.
In the post in early April, she said: “Women being cared for by core midwifery staff have been experiencing unacceptably long delays for induction of labour, resulting in bed blocking on the antenatal ward with enormous anxiety and frustration for all. Conversely, women being cared for under the continuity system have had a more streamlined experience, with timely care when required.
“I am conscious that this has led to many concerns being raised that there is now a two-tier system, where women are no longer being appropriately prioritised on clinical grounds. This has resulted in growing questions around safety within the unit and having worked with and listened to many of you, I share your anxieties.”
Dr Hillman said there was a large backlog of women waiting to be induced because of the “persistent challenges” around staffing. To try and tackle the problem she said continuity midwives would be expected to support patients on the ward.
But within hours this message was removed and a statement supporting the continuity of carer system put in its place.
In a second message on 10 April, Dr Hillman said she was resigning as clinical director, telling staff: “I am primarily a figurehead with a limited voice, or worse still a voice that needs careful adjustment and censoring by others.”
She claimed she was asked to re-write the message and post it again, which she said she could not accept, adding: “This shambolic train of events has rendered my position as [clinical director] untenable. Without the support of [the department], I have no authority and this undermining in so public a way has not only led to deep personal embarrassment but also significant confusion across the unit.”
Addressing the safety concerns, she said: “The unit is at best precariously safe … I cannot in all conscience continue to remain silent and simply watch and wait as events unfold.”
She said the unit was gridlocked on a “daily basis” with “inadequate numbers of midwives to address the workload”.
In a damning assessment of the trust’s rollout of the continuity of carer model, she said: “I remain unconvinced that continuity of carer is the benign ally that it is presented to be. I am concerned that it was initiated too quickly and with limited consideration to the impact on the core unit. We now find ourselves in a position where it is heresy to question the safety and validity of the situation and I am unable to continue to hold this party line.”
She said she felt strongly that the model had created a “two-tier system with preferential management for some, with clear detriment to others”.
Both messages were copied and shared widely among staff.
The trust said the message was removed from a closed Facebook group for maternity staff at the request “of another member of the team” and not management. It added: “This was not an attempt to censor Dr Hillman, but rather an attempt to have a more constructive discussion between colleagues.”
‘It’s such a stressful, horrible environment’
One midwife who spoke to The Independent said: “Catherine Hillman is on the shop floor; she works with the midwives and she's got a great relationship with everyone. She's well regarded. She has a voice and even she was shot down.
“The management aren’t present and just tell us we're going to be okay. It's frustrating, I just feel I can’t work in that environment anymore. It’s been going on for too long now.
Describing the risks for women, she said: “The women have been induced medically and they’re waiting to go to the delivery suite to have their waters broken. These women are told they’re high risk and that their babies could potentially die and then they wait for days on the antenatal ward for a midwife to become available so that they can be cared for on the delivery suite.
“Every time, as a midwife, you go to put a lady on a monitor to check the baby's heartbeat, you are literally hoping it's there and it's all ok. It's such a stressful, horrible environment.”
In one incident during December, a young woman in her early 20s collapsed and died on a maternity ward. An emergency caesarean section saved her baby’s life.
An investigation into her death is ongoing but a report to the trust board highlighted she had been on the ward for several days.
The trust’s maternity service was downgraded by the Care Quality Commission (CQC) after an inspection in December where the regulator also raised concerns over staffing levels.
At a meeting of the trust board in March, chair Sir David Nicholson, a former chief executive of NHS England who resigned in the wake of the care scandal at the Mid Staffordshire NHS Trust, said the CQC report “for me as chair of the board came as a bit of a surprise. It wasn’t something that our processes had alerted us to before it actually happened.”
He suggested work was needed as to why the board was “blindsided” by the CQC report.
This is despite whistleblowers raising concerns with the trust in September and October last year, ahead of the CQC inspection in December. There were six meetings with staff to discuss concerns, with minutes showing this directly related to the impact of the changes and their “main concern that they were not able to provide the level of care expected”.
The trust said Sir David was fully aware of the whistleblowing and the concerns raised that led to the CQC inspection visit and he had also visited the maternity unit himself to speak to staff.
The trust said it has recruited extra midwives included 17 newly-qualified staff to join the unit in September to improve staffing levels. It has also paused any further rollout of the continuity of carer model and will be evaluating its impact.
‘It has to be properly staffed and resourced’
The issues at the Worcester Royal could also be affecting units elsewhere if hospitals implement the same system in the same way.
NHS England has set a target to rollout continuity of carer in hospitals across the country, with trusts expected to offer the service to an increasing proportion of women this year – with all women expected to be on the maternity plan by March 2023.
In guidance to hospitals this month, NHS England made clear the risks for trusts, saying: “Some potential barriers need tackling at the outset, including putting adequate staffing in place.”
It has recently announced a near £100m investment in maternity staffing, but the Royal College of Midwives said it was concerned it didn’t go far enough, with the NHS already short of 2,000 midwives.
Gill Walton, chief executive of the RCM, said the college supported the idea of continuity of carer in maternity and believed it had the potential to improve care, but she added: “It has to be properly staffed and resourced for that potential to be realised.”
NHS England paused the rollout during the Covid crisis but has included it in its expectations for trusts over the next year.
Ms Walton warned: “To try to reinstate the implementation of continuity of carer now, or worse, to try to speed it up, places yet another burden on those midwives and maternity support workers, at a time when some of them are already looking for the door.”
The trust said there were no current delays on its maternity wards but accepted there had been some delays for women. It said this was not solely due to the continuity of carer model, arguing staffing shortages had also been caused by coronavirus, rota problems and delays in recruitment.
Matthew Hopkins, chief executive of Worcestershire Acute Hospitals Trust, said: “Our priority is, and always has been, the safety of our patients, which is why we are rolling out the continuity of carer programme which we have already seen has delivered real improvements for the experiences of women using our maternity services.
“We expect to fill all our hospital vacancies by the end of the month and our community services by the end of June – but we will of course continue to listen to the views of our staff about the continuity of carer programme.”
A spokesperson for NHS England said continuity of carer was “proven to significantly improve women’s overall experience of care and is safer for babies – it is also the care that women have said they want”.
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