It has been reported this morning that Derby maternity services’ rating has been downgraded to “inadequate”.

A report released today by the Care Quality Commission (CQC) comes following inspections at University Hospitals of Derby and Burton NHS Foundation Trust earlier this year, the most recent in August 2023.

It was reported in February 2023 that the deaths of 3 women under the care of Derby maternity services and 4 similar life threatening incidents may have been prevented if recommendations by the Healthcare Safety Investigation Branch (HSIB, which in April 2023 transformed into 2 bodies: Maternity and Newborn Safety Investigations Special Health Authority and the Health Services Safety Investigations Body) had been implemented earlier. These events all occurred between January 2021 and May 2022.

Following these incidents, the Trust asked NHS Derby and Derbyshire Integrated Care Board to perform an independent review to provide the families involved with “assurance that all possible learning had been identified”. At the time, the Trust’s executive medical director said “there has been learning for us as an organisation which we have taken very seriously, and the recommendations are invaluable in helping us further improve safety and the experience of women under our care”.

The latest CQC report sets out safety and leadership concerns. Some of the most worrying are:

• Staff did not always recognise and report incidents in line with trust policy and national guidance.
• The service did not investigate incidents in a timely way.
• Managers did not ensure learning from incidents was embedded to prevent re-occurrence of similar incidents.
• The service did not always have enough medical staff with the right qualifications, skills, training and experience to keep women, birthing people and babies safe from avoidable harm and to provide the right care and treatment.
• Staff did not always quickly act when women and birthing people were at risk of deterioration.
• Data from the Maternity summary report in June 2023 showed that staff correctly interpreted CTG traces in less than 60% of cases.
• The service did not have sufficient leadership capacity to effectively manage the service. Leaders were not always visible or approachable in the service for women, birthing people and staff.

Themes recognised in reported incidents over the past year included: maternity triage pathway, fetal growth pathway including management of fetal movements, CTG categorisation and escalation, lack of senior obstetric medical oversight / inappropriate delegation and management of major obstetric haemorrhages.

Most worryingly, the CQC reported that during the inspection, “it was not clear improvements had been made in relation to the above themes to prevent similar incidents occurring again”. This is evident from the deterioration in the maternity safety rating.

It has been acknowledged by the Trust that “learning from incidents was not always embedded”.

Derby maternity services are the latest in the East Midlands to be downgraded by the CQC. There is an independent review of maternity services currently underway in Nottingham, which is being chaired by Donna Ockenden. In September 2023, Leicester maternity services were downgraded to “requires improvement and maternity safety was rated “inadequate”. We have called for a review into Leicester maternity services as a matter of urgency to reassure families that improvements are being made.

There is also a call by the Maternity Safety Alliance for a national review into maternity services in the UK.

We represent families who have been affected by failures in maternity services across the East Midlands and the UK.

If you have concerns about the maternity care that you or a loved one has received please contact us for a no-obligation consultation. Our telephone number is 0116 254 7456 or you can contact us by email at enquiries@moosaduke.com