Inspectors demand improvements at maternity unit

Inspectors found issues with the assessment of women, monitoring of babies and management of severe incidents

Enforcement action has been taken against a hospital trust after inspectors found significant concerns at a troubled NHS maternity unit.

Problems over the assessment of women, the monitoring of babies and the management of severe incidents were highlighted as needing immediate improvement at Gloucestershire Royal Hospital.

The Care Quality Commission (CQC) has demanded action, including monthly updates from Gloucestershire Hospitals NHS Trust to ensure patients get safe care.

In a statement, the trust said action had been taken in the past year and it was disappointed it had not provided enough evidence of stronger reporting processes and shared learning to the CQC.

Hospital inspectors visited the trust in March, and said improvements they had previously demanded had not been made.

They have therefore issued the trust with a Section 31 notice, putting conditions on its registration and demanding urgent improvement.

The trust's management of post-partum haemorrhage has previously been criticised

These improvements include:

• Ensuring fetal heart rate monitoring is accurately assessed and escalated to senior clinicians in a timely manner to ensure it complies with national guidance

• Ensuring pregnant women are assessed and appropriately managed for the risk of haemorrhage

• Ensuring staff carry out blood clots assessments

• Ensuring agency staff are given proper inductions on the maternity unit

The trust’s management of post-partum haemorrhage has previously been criticised, in particular following the death of Rana Abdelkarim in 2021.

A previous CQC inspection in April 2022 also found problems in the handling of heavy bleeds.

• Watch: Midwives Under Pressure, BBC Panorama

At a meeting on Tuesday, the trust disclosed it had requested an external review of maternal deaths at the trust, following a recent edition of BBC Panorama.

A team from an arm of the CQC, Maternity and Newborn Safety Investigations, has been asked to examine all maternal deaths since 2018 to see if there are lessons the trust can learn.

The trust has told the Health Overview Scrutiny Committee of Gloucestershire County Council that maternity services in Stroud and Cheltenham will not open this year due to lack of staff.

'Service remains open'

In a statement, the NHS trust said the initial feedback after the CQC inspection was that “there were no immediate safety concerns and improvements had been made in the culture within the department".

It continued: "We are disappointed that we have not been able to provide enough evidence to the CQC of stronger reporting processes and shared learning, despite improvement work over the last year.

"The service remains open, and has a number of reporting conditions in place to ensure focused attention and pace.

"The service is required to report progress to the CQC on a monthly basis.”