The Care Quality Commission has ordered East Kent Hospitals Trust to implement an effective system for monitoring the safety of the environment and equipment at the maternity department at the Queen Elizabeth the Queen Mother Hospital and William Harvey Hospital in Ashford after concerns were raised at an unannounced inspection last month.
The Trust also has to report all actions carried out to ensure safety at the maternity units by noon on 24 February and by noon on the last Friday of each month thereafter.
The monthly reports must include results of any monitoring data and audits undertaken to show an effective clinical management system is in place and should include data and round checklists and equipment checks.
The Trust must also repair leaking roofs and bowing doors in the midwifery led unit and rusty shelf and flooring in the patient bathroom in the triage department.
CQC inspection
The monitoring follows an unannounced CQC inspection in January which raised concerns over the safety of women and babies in maternity units at QEQM and the William Harvey Hospital in Ashford which are both managed by East Kent Hospitals Trust.
Carolyn Jenkinson, CQC’s Deputy Director of Secondary and Specialist Healthcare, said: “We inspected maternity services at East Kent Hospitals University NHS Foundation Trust on 10 and 11 January 2023 and found a number of concerns. These primarily related to the safety of the labour ward environment, including the availability of regularly serviced equipment, processes for monitoring women and babies whose conditions deteriorate and risks of cross infection due to poor standards of cleanliness.
“Some of the issues identified are directly connected to the state of repair of the building and the limitations of the physical estate, which we recognise will require resources and greater external support to fully address. However, we have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care.
“As a result, we have used our urgent enforcement powers to impose conditions on the trust’s registration. These conditions require immediate action to ensure processes are in place to assess, manage and monitor the safety of the environment and equipment in the maternity department at both main hospital sites run by the trust and for regular updates to be provided to CQC on a monthly basis. Full details can be found on the relevant hospital profile pages on CQC’s website.
“We continue to engage closely with the trust’s leadership team and with NHS England who are offering expert guidance and support to the trust via the recovery support programme. We will report on our full inspection findings in due course.”
‘Urgent steps’
Sarah Shingler, Chief Nursing and Midwifery Officer, said:“We continue to work hard to improve our maternity services, including our work to listen to, involve and act on feedback from those using our care. Although a number of changes have been made, we know there is a lot more work to do.
“We take the latest concerns and action by the CQC very seriously. Our staff continue to work hard to improve our maternity services and we are taking further, urgent steps so that we can deliver the safe, high-quality care our patients and their families expect.
“A new dedicated fetal heart monitoring midwife has been appointed who will work alongside our clinical teams to ensure safe monitoring is consistently completed. This is in addition to introducing electronic alerts for staff when fetal monitoring indicates a risk to a baby or that a check is due. We have also increased medical presence to help safely triage women and babies and ensure there are no delays in treatment. We have increased the frequency of daily cleaning and have introduced daily checks on cleanliness and emergency equipment.
“We are committed to giving the CQC and mothers, babies and families using our maternity services confidence and the high quality care that they need and deserve.”
Maternity failings
The urgent enforcement conditions come on the heels of the damning independent report into maternity failings at QEQM and William Harvey Hospitals which found 45 baby deaths could have been avoided.
The report, led by Dr Bill Kirkup and published in October, reviewed the circumstances of maternity deaths at the East Kent Hospitals Trust sites in between 2009 and 2020 in response to a concerning number of avoidable baby deaths.
Issues with maternity were brought into the spotlight following the death of baby Harry Richford at Margate’s QEQM Hospital in 2017 after a series of errors.
The coroner ruled that Harry’s death had been avoidable. The inquest during January 2020 had heard of the “panic” after Harry was born by emergency Caesarean section during which his heartbeat kept dropping. Harry died seven days after his delivery from a condition caused by a lack of oxygen. An independent report said he might have survived had there not been a delay in resuscitation at his birth that caused irreversible brain damage. The coroner said there were 7 gross failings that amounted to neglect.
In 2021 East Kent Hospitals Trust was fined a total of £761,170 – inclusive of costs – for failing to discharge its duty to provide safe care and treatment, resulting in avoidable harm with the death of seven day old Harry Richford and sub standard care of his mum Sarah at QEQM Hospital in 2017.
Action plan
The Trust recently published an apology letter to the public and agreed a three year ‘transformation’ plan to tackle failures including a lack of compassion and failure to listen to women and denial at board level.
Actions will include an independent review of the board, a pilot ‘Calls for concern’ scheme to support patients of any age, their families and carers, to raise concerns if a patient’s health condition is getting worse or not improving as well as expected and a pilot ‘Civility Saves Lives’ in maternity, a programme to eliminate rudeness and incivility, which has been shown to have a positive impact on patient care.
Last March the Trust appointed a full-time Freedom to Speak Up Guardian for maternity, dedicated to listening to and supporting staff to raise concerns.
There will be more staff training and forums and a Reading the Signals Oversight Group which will include representatives from patients and families as well as the Trust’s Council of Governors.
The Trusts says there will be much more patient involvement and it will establish and implement a process for case reviews for families where required.
