Inspectors found there were not enough maternity staff with the right qualifications or training to keep women safe from “avoidable harm” at hospitals run by East Kent Hospitals University NHS Foundation Trust, and on occasions the shortages meant women were transferred to other hospitals during labour.
Two reports were compiled following inspections in July of maternity units and children and young people’s services at the Queen Elizabeth The Queen Mother Hospital in Margate and William Harvey Hospital in Ashford, and the community midwifery services at Kent and Canterbury Hospital in Canterbury and Buckland Hospital in Dover.
Visits were unannounced and carried out after receiving information of concern about the safety of quality of maternity services being offered by the trust.
Among the failings, inspectors found that staff often had to care for two women at once, increasing the risk of something going wrong during the birth, and the telephone service for advice during the pandemic had received so many calls that non-clinical staff with limited experience were answering and assessing women who were phoning in.
They also found that community midwifery teams did not visit all new mothers and their babies at home, instead carrying out telephone assessments, which was not in line with national guidance, and senior leaders at the trust were failing to “manage the priorities, risks, issues and challenges the service faced”.
Amanda Williams, CQC’s head of hospital inspection, said: “When we inspected the maternity services, we were concerned that there were not enough midwifery staff and maternity support workers to keep women and babies safe.
“We were also concerned that some staff were feeling exhausted, stressed and anxious, because mistakes can easily be made when people’s judgement is impaired by fatigue.
“At the time of the inspection, managers weren’t doing enough to effectively tackle this shortfall and were offering staff financial incentives to work above their contracted hours, and asking community midwives to take on additional work in the acute units, which meant they were sometimes working 20-hour days, with very little time for a break.
“We were also concerned to learn that staff did not always take the time to report all incidents around staffing and capacity issues. Staff felt that continually reporting short staffing had not improved the situation.”
In June, the trust was fined a record £761,000 following a landmark prosecution by the CQC over its failure to protect baby Harry Richford and his mum Sarah Richford from avoidable mistakes that led to Harry’s death.
Harry died as a result of “wholly avoidable” mistakes by staff at the Queen Elizabeth The Queen Mother Hospital in November 2017. He was delivered by caesarean section but delays helping him to breathe led to him suffering a severe lack of oxygen and brain damage.
A coroner ruled the mistakes amounted to neglect by the trust which had failed to act on earlier safety warnings that could have helped prevent the tragedy.
Last year the trust was also forced to apologise after a six-week-old child was found to have died due to mistakes at the same Margate hospital.
Luchii Gavrilescu was sent home with a mottled rash, erratic breathing and reduced feeding in November 2019. He was returned to Queen Elizabeth The Queen Mother Hospital where he died hours later of tuberculosis.
However, following the latest inspections, the report noted that improvements had been made in the service, and senior leaders were said to have recognised that the culture needed to change so that patients and staff could raise concerns.
The report also highlighted that staff worked well together, supported women to make decisions about their care, and identified and quickly acted upon women at risk of deterioration.
After inspectors raised concerns about unsafe staffing levels, the trust responded swiftly and produced an action plan including reopening the midwifery led unit, which was closed due to staffing issues, and suspending the homebirth service so that homebirth midwives could be redeployed to the maternity unit at the hospital.
Ms Williams added: “On a more positive note, during our inspection, we witnessed an emergency delivery where staff and embedded processes worked well together, resulting in the safe delivery of a baby at the Queen Elizabeth The Queen Mother Hospital.
“In the services for children and young people, I am pleased to report significant improvements since our last visit and it was clear that leaders and staff were committed to continually learning and improving services.
“The trust knows what further improvements must be made across both of these services, and we will return to check on their progress.”
Sarah Shingler, East Kent Hospitals University NHS Foundation Trust’s chief nursing officer, said: “We are pleased that the CQC has recognised the hard work and commitment of staff and the significant improvements that they have made for children, young people and their families.
“We continue to work hard to support our midwives’ well-being and help them provide a safe, high-quality service for women and babies. This includes a £1.6m investment to fund an additional 38 additional midwives with 26 already in post.”
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