East Kent Hospitals maternity services rated Inadequate as Care Quality Commission uncovers shocking findings
Published: 00:01, 26 May 2023
Updated: 13:50, 26 May 2023
Damning inspections of maternity units across east Kent uncovered blood-stained toilets, dirty equipment on wards and a risk of babies being misidentified.
The Care Quality Commission also found chronic staff shortages, poor infection control and vital resuscitation equipment being stored in corridors during its unannounced visits.
Shocking reports published today shine a light on the alarming failures unearthed at the William Harvey Hospital in Ashford and QEQM in Margate.
So damning were the findings that maternity services across the East Kent Hospitals Trust, which runs the sites, have been given the worst-possible rating by the care watchdog.
The publication of the reports is the latest scandal to beset the trust, which in October last year apologised “unreservedly” to parents after an independent investigation found 45 baby deaths since 2009 would likely have been prevented with proper care.
Known as the Kirkup Inquiry, it had involved more than 200 cases being looked at by an expert panel chaired by Dr Bill Kirkup.
The CQC inspections took place three months later, on January 10 and 11, but the findings were only released today.
They reveal the trust was ordered to take urgent action to keep women and babies safe following the surprise visits, with the BBC reporting today that it was told the CQC considered shutting the unit at the William Harvey.
Deanna Westwood, the CQC's director of operations south, said: “Over the last few years we have monitored the maternity services at East Kent Hospitals University NHS Foundation Trust closely, and where we have found action is needed this has been made clear so that the trust knows exactly where it must make improvements.
“Yet despite this we still found concerns, and it is extremely disappointing that this latest inspection found a further decline in the quality of care people were receiving.
“That is why we have used our urgent enforcement powers to require immediate improvements.”
Following the inspections both hospitals had their overall ratings for maternity services reduced from Requires Improvement to Inadequate - the lowest possible.
The reports reveal that the CQC found women and babies were being treated in a “chaotic environment”.
On one maternity ward at the William Harvey inspectors found dirty and dusty equipment, blood-stained toilets and cleaning records not filled in on 23 out of the previous 70 days.
In the triage unit the watchdog “routinely” observed staff not washing their hands or wearing gloves and aprons when delivering care to women, putting them at risk of infection.
There was a severe shortage of staff, with inspectors told of an instance when one midwife was left on their own in triage with 12 high-risk women waiting admission
Some areas of the hospital, which was built in 1977, were said to be “no longer fit for purpose”, with the labour ward and delivery suite described as “small and cramped”.
So small were some rooms that vital resuscitation equipment for babies - called resuscitaires - were having to be stored along a corridor, potentially delaying emergency care.
It also meant newborns being moved away during a “potential life-threatening and worrying time”.
Mrs Westwood said of the issue: “This could potentially result in delays in vital care and treatment for newborns, as well as separation from the mother and an increase in the potential for babies to be misidentified.”
In its report, the CQC set out the process needed to stop the horrifying event of a baby being mistaken for another.
“The midwife transporting the baby should firstly ensure the baby was clearly labelled prior to leaving the room and they must stay with the baby,” it read.
The Trust has since reconfigured its maternity rooms to allow space for resuscitaires.
The CQC found there were “low levels of staff satisfaction, high levels of stress and work overload” among hospital employees.
At the QEQM the harassment, bullying or abuse of ethnic minority staff by patients, relatives or the public was worse than the national average.
A potential security risk was also identified in that the hospital had no system to control who exited the maternity unit.
Inspectors wrote: “Reception staff could control who entered the unit and staff were encouraged to challenge individuals who were not wearing an identifiable wristband.
“However, the service did not have a system to control who exited the unit, which was a potential security risk.
“The service had an infant and child abduction plan; however, this was past its review date of November 2022.
“Inspectors were told this was currently under review.”
Away from the catalogue of failures, inspectors heaped praise on the service provided by the William Harvey’s breastfeeding support team and its bereavement service, which it said “supported women and their families appropriately and sensitively”.
They also found that people using maternity services at the QEQM were “treated with compassion and kindness by staff”, who gave “emotional support to families and carers”.
East Kent Hospitals’ chief executive Tracey Fletcher said: “I am sorry that despite the commitment and hard work of our staff, when they inspected in January, the CQC found that the Trust was not consistently providing the standards of maternity care women and families should expect.”
She says the trust acted “at once” to respond to safety concerns raised.
“Our staff are determined to improve our services for patients...”
It has increased doctor staffing in the triage service at William Harvey Hospital, which it says has improved the time in which women are seen by a doctor.
Changes have been made to ensure better access to and regular checking of emergency equipment.
Staff now have electronic alerts when a foetal monitoring check is due and it has ensured all workers have completed foetal monitoring training.
A new foetal heart monitoring midwife has been appointed who works alongside its clinical teams and cleaning has been increased.
Mrs Fletcher added: “Our staff are determined to improve our services for patients.
“The CQC reports recognise the compassion and kindness they have shown to women and families and the outstanding practice of the service in proactively listening to and seeking feedback from every person who gives birth with us about what we can improve.
“To date, we have spoken with more than 3,600 families, and have received positive feedback on our service as well as areas we need to improve.
“We are making changes from what they tell us, such as improving facilities for partners and improving choice of pain relief options.”
Mrs Fletcher says 90% of these families say they “were positive about their care”, but the trust will “continue to listen” and act so people can have “greater confidence” in services.
“We recognise that, despite the changes that have been made to the service so far, there is a lot more to do to ensure we are consistently providing high standards of care for every family, every time,” she said.
“We are continuing to work hard to improve the culture and multi-professional team working highlighted by Dr Bill Kirkup through the independent investigation into our maternity services, including implementing ‘civility saves lives’ staff training.
“I am grateful to the families who are helping us as we seek to make these improvements, and to our staff for their commitment.”
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