Damning report calls for 'immediate improvements' to maternity and neonatal services in Leeds
The CQC has downgraded maternity services at the Leeds Teaching Hospitals Trust.
A devastating report from healthcare regulators has called for 'immediate improvements' at maternity units in Leeds, after parents came forward to report poor care.
Maternity services at both Leeds General Infirmary and St James' have been downgraded from 'good' to 'inadequate' overall, according to the Care Quality Commission (CQC).
The regulator carried out an unannounced inspection of maternity and neonatal services at both hospitals late last year and earlier this year to follow up on concerns received from whistle-blowers and families.
Among the findings on Leeds' maternity units were:
- Staff did not always have 'meaningful interactions' with the people they cared for, with short staffing meaning they couldn't spend much time with a single patient.
- The environment was not always safe for people. Some areas were dirty which could put people at risk of infection.
- Staff were reluctant to raise concerns as they felt the trust had a 'blame culture' rather than seeking to learn from mistakes
- Medicines were not always stored or managed safely to make sure that people were not at risk of harm.
- Staff understood the risks to people as they moved through different services, however records weren’t always completed showing how those risks were assessed.
In neonatal services inspectors found:
- Leaders hadn’t ensured there were always enough staff with the right qualifications and skills to meet the needs of babies.
- The trust hadn’t ensured there was a designated private space for mothers to breast feed or express breast milk.
- Leaders didn’t ensure the environment was always safe. Equipment wasn’t always safely secured.
- Medicines were not always stored correctly, and some were out of date.
Ann Ford, CQC’s director of operations in the North of England, said: “Prior to our visit, we had received a number of concerns from staff, people using the services and their families about the quality of care being delivered, including staff shortages in maternity at both hospitals."
"During the inspection, the concerns were substantiated, and this posed a significant risk to the safety of women, people using these services, and their babies as the staff shortages impacted on the timeliness of the care and support they received."
Fiona Winser-Ramm's daughter Aliona Grace died 30 minutes after her birth in 2020, with the new mum accusing doctors of neglect.
"This is the first time there's been any kind of real public recognition of everything that we have been saying... not just, as (the hospital trust) have made out, us being angry parents."
"Still everyday I think I'm going to wake up from this absolute nightmare and I can't believe this is my life now.
"My daughter deserved to be here, we deserved a life with her. She was perfectly healthy and they neglected her and killed her"
A statement from the Bereaved and Harmed Families group, which is made up of families affected by maternity failings at Leeds, said:
"The previous CQC inspection... somehow rated the hospital and maternity services as “good”, angering bereaved and harmed families, as safety failings have not appeared out of nowhere in the last two years in the run up to this inspection; they have been systemic for 5-10 years, if not more."
"Therefore, serious questions need to be asked about what the CQC did, or more likely, did not do, before, during and after that 2023 inspection and its subsequent report.
"These questions become even more pertinent when you consider that it took for families to pressure and complain to the CQC to get this re-inspection to happen.
"How many babies could have been saved if the CQC had listened or properly detected these failings sooner, as they should have done?"
Chief Executive of the Trust, Professor Phil Wood said: “These reports have highlighted significant areas where we need to improve our maternity and neonatal services, and my priority is to make sure we urgently take action to deliver these improvements.
“I want to reassure every family due to have their baby with us in Leeds and any new parents that we are absolutely committed to providing safe, compassionate care.
“We deliver more than 8,500 babies each year and the vast majority of those are safe and positive experiences for our families.
"But we recognise that’s not the experience of all families. The loss of any baby is a tragedy, and I am extremely sorry to the families who have lost their babies when receiving care in our hospitals.
“It is vital that as a Trust we listen more to our families and understand their experiences and concerns so we can address these and ensure everyone’s experience is of the highest standard.
“We must ensure we have the right support in place to enable our staff to deliver safe and high-quality care to all our families.
"We have fantastic teams of dedicated, compassionate staff in our maternity and neonatal services and as part of the inspection the CQC spoke to many of them. I’d like to thank those staff for speaking up openly and honestly and raising their concerns, which included staffing levels and the culture of the services.
"I recognise we need to be better at listening to our staff and acting on their concerns and I’m sorry we have fallen short on this.
"I want to reassure staff that they can speak up and will be heard in a supportive way.
“We have already started making improvements to our services, including recruiting 55 midwives since autumn 2024 after additional funding was agreed by the Board last year.
"We are currently 11 midwives short of our nationally recommended target of 367 but we continue to actively recruit to meet this standard. A further 35 newly qualified midwives are due to start work with us this autumn. We appointed additional midwifery leadership roles to support our clinical teams to deliver safe high-quality care to all our families.
“We are addressing the concerns around culture within our maternity services; we have increased the number of Freedom to Speak Up Champions, encouraging staff to report concerns, and introduced regular ‘Time to Talk’ meetings for each staff group, and monthly open meetings with myself, the Chief Nurse and the Director of Midwifery and Nursing.
“Since the CQC inspections in December and January we have already improved our infection control and cleanliness with greater presence of matrons on our wards, visits and inspections to ward areas and the replacement of damaged furniture and equipment.
"We have improved our medicine storage and management, with a full stock audit and comprehensive checks implemented.”