08 Jun Learning from investigations into maternity services at East Kent
In the past year, several maternity units in the UK have received a lot of national attention. Investigations into the care they provide have revealed a wide range of pervasive issues, and drawn focus to areas that must be addressed by maternity services across the county.
Our intention is to highlight these themes for improving care with respect to the most recent investigations into the care at East Kent Hospitals University NHS Foundation Trust. The aim is to provoke reflection on local care and similar improvements that may be able to be made nationally.
At the end of May, the Care Quality Commission (CQC) published an inspection report into maternity services at East Kent trust. This followed unannounced inspections carried out at William Harvey Hospital, Ashford, and Queen Elizabeth the Queen Mother Hospital, Margate (QEQM) in January this year.
Maternity services at the hospitals were rated as “requiring improvement” overall, and also specifically in “leadership” and “safety”.
The trust is subject to an independent investigation, chaired by Dr Bill Kirkup. This investigation was announced following an inquest into the tragic death of baby Harry Richford, which concluded in January this year, and a campaign by Harry’s family for the proper investigation of wider concerns about the safety of maternity services at the trust.
In February this year, the Healthcare Safety Investigations Branch (HSIB) published a thematic summary report of the 24 maternity investigations it has commenced at the trust since July 2018. This report highlighted recurrent safety risks around several key themes, including:
- CTG interpretation
- Neonatal resuscitation
- Recognition of deterioration
- Escalation of concerns and responses
These themes echo many of the same findings as national investigations into maternity services, and so it serves as an opportunity for maternity services to reflect, learn, and potentially avoid preventable harm locally.
The Latest Published Report by the CQC
The CQC report found that the trust has made progress in some key areas but that several concerns relating to maternity care at the trust remained. These include:
Long waiting times
At the QEQM, inspectors found there were long waits for women within the antenatal day care, with one only midwife on duty during each clinic.
Skin-to-skin and breastfeeding concerns
Inspectors found midwives caring for women during routine caesarean section did not have enough time to support mothers with skin-to-skin and infant feeding in the first hour after birth, which is vital to stabilise babies’ blood sugars and temperature.
Incidents and risks were not always reported
Inspectors found staff in day care did not routinely report all incidents, which meant managers were not always aware of all avoidable events on the unit.
The service did not always complete incident reviews according to national time frames.
The report stated that the service did not always manage infection control well. It also expressed concern at the location of the day care ward, with pregnant women accessing the waiting area via the main outpatients waiting area where people with long-term health conditions waited for appointments
The report stated that there were not always enough senior doctors in the day care clinic; women were reviewed and assessed by midwives. Women would only see a doctor if the midwife assessed concern or risk.
Midwives told the inspection team that a senior doctor was sometimes available in clinic; however, it was usually a junior doctor with limited obstetric experience that would review and discharge.
Inspectors found maternity day care admissions and wait times had not been routinely monitored, which meant staffing did not always meet the needs of the service. The report also found that on-call consultant and medical cover for maternity and gynaecology was limited.
Escalation of medical emergencies
The report highlighted that there were times when junior midwives, who did not have the necessary experience, knowledge and skills to escalate complex emergency situations, worked alone in day care.
Concerns over safety and risk assessments
Inspectors who visited the William Harvey Hospital said the trust had not achieved compliance with all 10 actions of its own safety action plan.
In maternity day care, standard operating procedures were not embedded, risk assessing women was not robust, and correct care pathways were not always identified quickly.
At the QEQM, inspectors said new maternity triage guidelines and risk assessments were not yet embedded within the service and they found concerns with the documenting of risk and escalation.
The report also stated that QEQM staff also were not using a “nationally recognised, competency-based tool” (Modified Early Obstetric Warning Score (MEOWS)) in triage to trigger escalation.
Where do we go from here?
The fact that the recent CQC inspection found some serious concerns about the safety of maternity services at East Kent will make sad reading for families affected by previous incidents at the trust.
A commitment to improving
It is important to note, however, that the CQC report does highlight a number of areas where positive changes have been made. In response to the report, the trust itself has reiterated its commitment to acting on the findings, and NHS England and NHS Improvement are now providing external support.
The themes identified at East Kent by both the recent CQC report and the HSIB summary report, are not unique to this trust alone.
To support safer maternity care, it’s crucial that:
- Local investigations improve – you cannot truly understand how “things go wrong” until local investigations are conducted which involve all relevant professional groups, external and family input.
- All staff who work together, also train together – something highlighted time and time again by national reports. Skills and competencies must be kept up to date, and communication and teamworking skills need to be regularly practiced. As a result, escalation may also improve.
- Rapid reflection and action plans
Although serious complications are rare, when they occur a good outcome can depend on how multi-professional teams communicate and work together, and how trusts reflect on when things go well as well as when things do not.
Relevant training courses provided by Baby Lifeline Training: