Care Quality Commission downgrades St George’s maternity service to inadequate

Posted: 20/09/2023

Last month, the Care Quality Commission (CQC) rated maternity care at St George’s Hospital in south west London as ‘inadequate’ following its inspection in March. The report raised numerous concerns about patient safety including insufficient staffing levels, failures to properly risk assess, lack of monitoring for delayed inductions, not following national guidelines, unsafe fetal monitoring and downgrading of serious incidents. The CQC described the service as ‘a chaotic environment without clear organisation or leadership’.

With yet another maternity unit in the country under scrutiny, it is easy to feel as though maternity services in the UK are in crisis. Various inquiries over the previous 10 years have identified worrying trends and systemic failures in the care that is being provided to mothers and babies. Some of these inquiries are prompting criminal investigations to further explore the standard of care that was offered.

Of key importance and significant concern is the fact that similar problems are being identified over and over again, across various trusts, and it seems that lessons are still not being learnt. The culture of cover-ups and the downgrading of incidents thwarts any opportunity for learning which would help to implement change and prevent future deaths and injury.

Sarah Hibberd, a clinical negligence solicitor at Penningtons Manches Cooper specialising in maternity claims, comments: “Sadly, as maternity lawyers, time and time again, we see clients who have experienced similar failures in their maternity care. Surely, if we can see these worrying trends developing, it should also be apparent to the NHS. If so, why aren’t trusts reviewing their practices, learning from mistakes and implementing training and policy changes to prevent further harm?”

What is the CQC?

The CQC is an independent body that regulates health and adult social care in England.

The commission has begun a maternity inspection programme, triggered by the recent maternity scandal in Shrewsbury and the subsequent Ockenden review, which concluded that hundreds of babies had died or suffered brain damage as a result of inadequate care. The CQC is reviewing all maternity services that have not had an inspection in the last few years in an attempt to identify any maternity units where patients are at risk. The services can be ranked as ‘inadequate’, ‘requires improvement’, ‘good’ or ‘outstanding’.

Of the services that have been given a rating under this inspection programme so far, around half have been rated as either ‘inadequate’ or ‘requires improvement.’ This is extremely concerning and indicates ongoing and widespread disarray within maternity care.

St George’s maternity service under observation

In March 2023, the CQC reviewed the maternity services provided at St George’s Hospital NHS Foundation Trust.

Previously its maternity service had been rated as ‘good’ with some aspects of the service rated ‘outstanding’. St George’s Hospital has also been listed as a specialist centre of excellence by NHS England, under its campaign to reduce maternal mortality rates by establishing a network of specialist treatment centres for women with complications or conditions arising before and during pregnancy. The hospital has a reputation for the management of complex maternity issues, with a referral system in place for expectant mothers to have their care transferred to St George’s should complications arise.

This makes the CQC’s decision to downgrade St George’s maternity service to inadequate even more shocking.

Key concerns

The CQC report, published on 17 August 2023, identified the following key areas of concern at St George’s:

there were insufficient staff to keep women, birthing people and babies safe;
staff were not being supported to complete mandatory training;
infection prevention and control measures were not being effectively carried out and several areas were found to be dirty and poorly maintained;
medicines were not always being stored safely;
staff did not risk assess women and there was no prioritisation tool to support staff in quickly assessing those in most clinical need;
staff reviews of fetal monitoring in labour were not safe;
the severity of incidents was frequently downgraded and harm-ratings were inappropriately assessed which limited the opportunity for learning and improvement;
a poor culture within the staff groups. Service leaders and safety champions were not visible to staff. Safety champions were not embedded in the service and had limited, superficial knowledge of the unit;
support for the service from executive level was poor, and executive leaders failed to recognise the severity of the issues faced;
data showed disparity between the experiences of ethnic minority staff and white staff and staff were undervalued and not supported by managers; and
the service did not take swift action to mitigate the serious risks of staffing levels;
implementation of improvement action plans was slow or not evident;
governance processes were not effective.

Sadly, many of the themes seen within this CQC report appear to be problems facing maternity services across the country.

Staffing levels and training
The CQC inspection confirmed that ‘the service did not have enough maternity staff with the right qualifications, skills and training and experience to keep women and birthing people safe from avoidable harm…… Training days were regularly postponed to free up staff to work clinically on days when there were staff shortages…The impact of this was staff not being up to date in their training and there was a risk that staff provided inappropriate care.’

Risk assessment
The report confirmed that ‘staff did not complete risk assessments for each woman and birthing person’ and ‘did not use a standardised risk assessment framework or priorisation tool to identify women and birthing people in the most clinical need’.

CTG monitoring
One of the most worrying concerns highlighted by the CQC was that ‘fetal monitoring in labour was not safe’ and staff were assessing and documenting ‘CTGs using various techniques which was not in line with trust guidelines, inconsistent, and potentially caused delays in timely escalation and review’. CTG monitoring is a key tool in understanding babies’ welfare during labour so failures in performing this essential monitoring and escalating any concerns can have devastating outcomes. The CQC found that ‘safety concerns relating to CTG monitoring and interpretation were reported in an incident review in 2018’ and ‘it was not clear why inconsistent review techniques were still being used by the service in 2023’.

GROW charts
The report also noted the service did not use ‘customised growth charts or conduct symphysis fundal height measurements to monitor fetal growth which was not in line with national recommendations’. Fetal growth charts are of central importance in understanding whether a baby is more at risk of harm and whether they are likely to have limited reserves during labour. The trust stated that it currently uses ultrasound scanning as an alternative. However, ‘there was no fetal growth assessment for low-risk pregnancies until 36 weeks, which may not be adequate in identifying and monitoring babies with growth restriction.’

Induction of labour
The report highlighted that ‘women and birthing people experiencing delays in induction of labour were not risk assessed, monitored and managed safely all of the time’. Guidance was not always followed and ‘delayed induction of labour had led to adverse outcomes for families’.

Inappropriately grading incidents
Concerningly, the CQC inspection also found that when incidents occurred, they were ‘harm-rated inappropriately according to national guidelines (NHS England National Reporting and Learning System, 2019), with incidents often harm-rated at a lower grade than appropriate’. Incidents were discussed at serious incident declaration meetings (SIDM) but evidence showed that they ‘regularly graded incidents inappropriately for review as ‘adverse incidents’ instead of ‘serious incidents’ including stillbirths, massive obstetric haemorrhage and uterine rupture’. This meant the incidents were investigated internally, rather than reported nationally, leading to a ‘missed opportunity for learning and development to provide the safest care possible, and a lack of transparency at executive level in sharing serious incidents’.

Failure to learn from previous baby death

The CQC found that ‘improvements required in practice were identified following the serious incident of a baby death in 2018; CTG interpretation, handover of care, learning lessons from poor outcomes and investigating incidents in a timely way’. The CQC inspection confirmed that these themes were ‘ongoing within the service nearly five years later…indicative of ineffective governance and risk management systems, and ineffective learning from incidents taking place’.

The recent CQC report indicates that very little has changed, despite these historical concerns, and this begs the question, why are managers not listening to concerns and taking serious steps to ensure their maternity unit is fit for purpose? In a statement to the Health Service Journal, St George’s said: “We take the CQC’s findings extremely seriously and accept that standards on our maternity unit have fallen below what we expect. We have taken immediate action to address the CQC’s concerns.” For families who have lost babies, or have babies living with life altering injuries as a result of St George’s failures, the question will remain, why did it take a CQC inspection for the trust to acknowledge concerns that have already been raised by patients, staff, the coroner, the ombudsman and external reviewers? If they had changed their practices when they first learnt of these concerns, how many lives could have been saved?

CQC serves warning notice on the trust

As a result of the CQC’s findings, it has served a warning notice on the trust, requiring the maternity service to make significant improvements. Some of these improvements include:

the timely and effective triage of women and birthing people;
safe levels of staffing;
safe care for women in labour especially in relation to fetal monitoring;
ensuring women and birthing people experiencing delays in induction are managed and monitored safely;
incidents should be well managed, including effective sharing of learning, using learning to effect change and improvement in practice, ensuring incidents are categorised, harm rated, investigated, referred for external review and reported accurately and appropriately;
improvements in governance and oversight of the service.

St George’s is required to submit an action plan to the CQC, which will continue to monitor the hospital’s progress in relation to these improvements. It is hoped that the trust will now take steps to improve its standard of care but it will of course be frustrating for many families to find out that lessons have not been learnt from previous incidents and changes have not been made to ensure safer practices within the maternity service.

Penningtons Manches Cooper’s specialist maternity team is investigating claims relating to the standard of care that has been provided by St George’s maternity service. There are recurring themes of inappropriate advice on induction and inadequate fetal monitoring, both of which can lead to babies being born with serious brain injury, stillborn or dying within the neonatal period. Families who have experienced traumatic birth or bereavement have been devastated to learn that, despite raising their concerns repeatedly with the trust, and fighting for change so that no one else suffers the same fate, they have not been listened to and the same problems are still evident.

It is apparent from the CQC report that there has been ‘ineffective action by leaders to resolve and mitigate’ ongoing problems and a tendency to cover up the extent of the problems by downgrading ‘serious incidents’ to ‘adverse incidents’. By downgrading concerns, presumably in an attempt to protect the trust’s reputation and limit external investigations, recurring problems were not identified, change was not implemented, and more mothers and babies have been put at risk.

“The CQC report is a very public acknowledgment of the trust’s failings,” says Sarah Hibberd. “Hopefully, this scrutiny will be the impetus the trust needs to implement change and the leaders will be held accountable if that change is not forthcoming.

“With the CQC inspecting over 100 maternity services, and similar trends emerging across the country, it is a very concerning time for families who are uncertain what the future holds for maternity services and whether, at one of the most vulnerable stages in their life, they will be provided with safe and appropriate care.”

Penningtons Manches Cooper has a dedicated team of specialist maternity lawyers, with experience ranging from retained products of conception to birth injury, stillbirth and neonatal death. We hope that by assisting families who have faced negligence, we can encourage the NHS to implement the change that is urgently needed within maternity services.

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