New CQC concerns over troubled maternity service

• CQC raises concerns after inspection last month
• Issues highlighted focus on triage and day care
• Trust says multiple actions have been taken

Midwives at a hospital trust at the centre of a maternity investigation were having to make decisions on the treatment of high risk women which should have been made by doctors, the Care Quality Commission found in an inspection last month.

The concern was among inspectors’ findings at the Queen Elizabeth, the Queen Mother, Hospital in Thanet, set out in a summary of concerns sent to the trust shortly after their visit.

The CQC said it presented a risk to women seen by triage and day care services at the hospital, run by East Kent Hospitals University Foundation Trust, whose maternity services have been the subject of growing concern in recent weeks.

The trust’s triage service is for women with concerns about their pregnancy — who may phone in, for example, about changes to their babies movements. The day care service is for women with high risk pregnancies who need more regular monitoring.

The CQC’s feedback letter, published by the trust yesterday, said it had identified concerns in both services, including problems involving appropriate escalation and senior staff support. The FT has maternity units at the QEQM and at the William Harvey Hospital in Ashford. 

The concerns included:

• Midwives having to make decisions which should have been made by doctors about high risk women at the QEQM;
• Junior nursing staff at the William Harvey were rostered with responsibility for women in day care without sufficient senior support;
• Early warning scores were not being calculated to see whether care and treatment needed to be escalated;
• Risk monitoring of women was not robust, and correct care pathways not being identified;
• Midwives may not be escalating cases of fetal distress to medical staff. The letter said the trust was aware of this risk; and
• The CQC added it wanted to “develop a further understanding of how the trust makes sure it addressed the out-of-hours provision for both gynaecology and the labour wards”.

NHS England and Improvement commissioned an independent inquiry into East Kent’s maternity services yesterday, after a spate of concerns emerged following coverage of the case of Harry Richford. His death in November 2017, a week after his birth at QEQM, was described as “wholly avoidable” at his inquest last month.

A number of other families who have lost babies either in the womb or at birth have since come forward. Many of their concerns include fetal heartbeat monitoring and involvement of more senior staff.

The trust has admitted some of the deaths could have been avoided but there has been confusion over how many. In a BBC interview, trust chief executive Susan Acott said there were “six or seven” judged to be avoidable since 2014, while at yesterday’s board meeting she suggested there were 15 — although this appears to relate to a longer period.

In response to the CQC letter, Ms Acott said the trust was supporting midwives to make decisions about women who approached the triage service through a flow chart and a red-amber-green risk rating system had been put in place following the CQC visit.

Maternity early warning score charts had been introduced since the CQC visit, she said, and a full clinical assessment would determine if a registrar or consultant should be involved.

Women attending the day care unit did have a clear management plan, developed with their named consultant, and any changes in mother or foetus led to the obstetric team on-call being involved, Ms Acott added in her response letter.

In addition, gaps in the rosters were being addressed to ensure there was always a band six or seven midwife present to support more junior staff. Additional band seven midwifes were being recruited to ensure oversight of the triage area.

She added consultant cover had been increased from 70 hours a week to 87.5 hours, although the trust needed to recruit additional staff to make this sustainable, and attendance at labour ward handovers and evening telephone conference calls was audited. Guidance on consultants’ attendance out-of-hours has been updated since Harry Richford’s inquest, she said.