CQC downgraded maternity services at Hampshire Hospitals NHS Foundation Trust after inspection was prompted by staff whistleblowing

Posted: 09/10/2023

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Evidence at a two week employment tribunal in Southampton has echoed the findings of a Care Quality Commission (CQC) inspection into maternity services at Hampshire Hospitals NHS Foundation Trust that last year led the CQC to conclude the care provided was not safe and required improvement. The inspection was called after concerns were raised from several sources across the trust, including staff whistleblowing, which is pertinent given the employment tribunal - of Martyn Pitman, a former senior obstetrician and gynaecologist at the trust - which concluded this week.

Martyn gave evidence to the tribunal that before his employment was terminated, he raised concerns about patient safety at the trust but these were dismissed by managers and he was victimised as a result. He stated that the merger of the Royal Hampshire County Hospital with Basingstoke and North Hampshire Hospitals NHS Trust in 2012 ‘proved challenging due to significant differences in the philosophy of care and management style’, which included an emphasis on natural birth over caesarean sections.

Wide-ranging findings of the CQC investigation

From a patient safety perspective, some of the most concerning findings set out within the Hampshire Hospitals report, which was released on 28 January 2022, were those of higher than national average rates of poor patient outcomes including:

• babies being born with an Apgar score of between 0 and 6 (being born in poor condition);
• third and fourth degree maternal tears (also known as obstetric anal sphincter injuries).

Other important concerns about the care from a patient safety perspective, which are likely to have contributed to these higher-than-average poorer outcomes, were:

• lack of correct midwifery staffing levels for safe care delivery;  
• two-day delays in providing inductions of labour with a delay in this care by over two hours known to be a midwifery red flag event identifying that there may be problems with staffing;
• staff not attending mandatory training as they were needed to provide care on the unit;
• senior staff not creating a culture which supported individuals;
• a failure to learn from previous incidents and to share knowledge and learning;
• a lack of important policies and protocols, such as how to respond to reduced fetal movements.  

Specific to Basingstoke, there were other concerns including:

• increased rates of third and fourth degree tears compared to the national average;
• staff being allocated tasks beyond their competency level with some feeling out of their depth with high-risk cases and unable to say no;
• staff not always identifying women at risk of deteriorating quickly.

Specific to Winchester, there were concerns that:

• the emergency call bell was not working in the day assessment unit posing a risk to women in an emergency.

The controversy surrounding ‘natural birth’

The ‘natural birth’ debate extends far beyond the area served by the trust. Over recent years there has been some controversy nationally surrounding what was termed a desire for natural births and the possible unintended consequences where there is a reluctance to offer caesarean section delivery. This was specifically raised in the Ockenden report into the care provided at The Shrewsbury and Telford Hospital NHS Trust, in that the low caesarean rate of 14% in 2005, compared to the UK national average of 23.2%, was presented as demonstrative of good practice but there was no scrutiny alongside this of unplanned admissions to the neonatal intensive care units, rates of hypoxic ischaemic encephalopathy and other relevant near misses. Extensive recommendations were made by Donna Ockenden and one essential action arising from her report was that ‘all trusts must ensure that women have ready access to accurate information to enable their informed choice of intended place of birth and mode of birth, including maternal choice for caesarean section delivery’.  

Lack of policies on the management of patient care

There has been a very significant focus in recent years on highlighting the importance of reduced fetal movements for identifying cases where intervention may be needed. Campaigns from Tommy’s and Kicks Count have pressed the significance of mothers paying attention to their babies’ movements and taking themselves for assessment if they see a change in movement patterns. Despite this, the CQC inspection noted that neither Winchester nor Basingstoke Hospital had a policy for the management of reduced fetal movements at the time. A lack of policy guidance on an important area of clinical management can lead to inconsistent care provision and poorer outcomes.

Low Apgar scores and their significance

An Apgar score is a measure for professionals to assess the health of newborn babies at one and five minutes after birth, with scores of seven and above classed as normal, scores of four to six as fairly low and scores of three or below as critically low. The higher than average level of Apgar scores in the ‘fairly low’ and ‘critically low’ brackets suggests therefore that more babies have been born in a poorer condition at Basingstoke and Winchester Hospital than would generally be expected. This does not necessarily mean that there has been any clinical negligence in the care provided but may suggest that there are some issues surrounding the management of babies’ deliveries.

Third and fourth degree maternal tears

A third-degree tear extends into the muscle that controls the anus, whereas a fourth-degree tear extends further into the lining of the anus or rectum. These tears are more likely when there is a ventouse or forceps delivery (which can happen in response to a baby in distress or if the labour is not progressing), and if the baby is large, but this is not always the case.

A third- or fourth-degree tear will usually need to be repaired in the operating theatre soon after the baby is delivered. Antibiotics will normally be prescribed to reduce the risk of infection, laxatives may be used to make it easier and more comfortable to open the bowels and post-discharge physiotherapy follow up will be available. Efforts are made to avoid third- and fourth-degree tears as these can lead to incontinence.

What constitutes clinical negligence?

In order to prove a clinical negligence claim, the patient must show that no responsible body of medical professionals with the same skill would support the care given and that with the correct care it is more likely than not that the outcome would have been different. This involves detailed consideration of the medical records and evidence provided by specially trained medico-legal experts to identify whether the poorer outcome arises due to an unfortunate complication or because of negligence. Our specialist team has significant experience in investigating maternity care and presenting claims where respected medical experts identify that the treatment received was negligent.

Helen Hammond, a senior associate in the clinical negligence team at Penningtons Manches Cooper with a special interest in maternity care, comments: “One frustrating aspect of the CQC report, which reflects our experience of representing local families whose babies have either died or developed brain injuries due to the management of their birth, is the failure to learn from previous incidents to prevent them reoccurring. Many families we have worked with have expressed a desire for the harm they or their child have suffered to lead to safer care for those who follow them. Acting on the findings of the report to make this the case would create a lasting legacy.”

Other articles in this series

• The lessons to be learned across the NHS following the Lucy Letby verdict
• Care Quality Commission downgrades St George's maternity service to inadequate

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