Mothers were forced to share food at one of England’s biggest NHS trusts

Hungry women had to share food and emergency calls for help were ignored at one of the biggest hospital trusts in England, a report warned today.

Hospital inspectors have expressed serious concerns over the safety of mothers and babies at Sheffield Teaching Hospitals NHS Foundation Trust.

It comes just days after the publication of the Ockenden report, which unearthed harrowing details about the worst maternity scandal in the NHS’s 70-year history at Shrewsbury.

England’s health watchdog, the Care Quality Commission (CQC), have downgraded the Sheffield trust’s rating to ‘requires improvement’.

Inspectors said they were worried about they way maternity services are being run.

They raised concerns about the ‘inadequate provision of food and drink’ to patients, and highlighted one example of women having to share food in the trust’s dedicated maternity ward called the Jessop Wing. 

‘An example given was of a neighbouring patient giving someone the food and drink they required,’ inspectors said.

Another concern that was flagged stated how staff ignored calls for extra help when a woman’s health was deteriorating. 

‘Staff told us there were occasions when they would “bleep” for medical assistance on more than one occasion before assistance arriving,’ CQC inspectors said.

The damming inspection comes just a week after the Ockenden report revealed 201 babies and nine mothers died needlessly during a two-decade period of appalling care at the Shrewsbury and Telford Hospital NHS Trust.

Senior midwife Donna Ockenden, who authored the report, warned that childbirth in England will be unsafe until all 15 of her recommendations were implemented across all NHS trusts. 

The CQC said Sheffield Teaching Hospitals NHS Foundation Trust had failed to make required improvements to services when inspectors visited in October and November, despite receiving previous CQC warnings.

As well as concerns across the wider trust, a focused inspection on maternity found deep worries about the way its services are run.

Inspectors found the Jessop Wing did not have enough midwifery staff with the ‘right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment’. 

The CQC previously identified significant patient safety concerns in March 2021, which saw the rating of its maternity service deteriorate to inadequate.

However, inspectors said their reinspection found ‘there was little or no improvement to the quality of care patients received… in some areas the service had deteriorated further’.

They added they had ‘significant concerns about the assessment of patients in the labour ward assessment unit, maternity staffing and delays in induction of labour’.

Inspectors found that staff were not interpreting, classifying or escalating cardiotocography (CTG) readings properly, which measure a baby’s heart rate.

Failures to correctly measure baby’s heart rates are similar to concerns raised in the Ockenden report into Shrewsbury and Telford Hospital NHS Trust. 

The CQC said that in its reinspection of Sheffield, from October 5 to November 11, documentation on CTG was poor and not in line with national guidelines.

Despite foetal monitoring being highlighted as an area needing attention as far back as 2015 the most recent inspection found improvements had failed to be carried out. 

‘The service continued to lack urgency and pace in implementing actions and recommendations to mitigate these risks, therefore exposing patients to risk of harm,’ inspectors said.  

Inspectors also found there were inadequate risk assessments for patients which meant ‘shift changes and handovers did not always include all necessary key information to keep women and their babies safe’.

The CQC’s analysis of the Trust’s data from April to October 2021 showed a ‘total of 35 patient safety incidents had been raised due to lack of suitably trained/skilled staff’.

One employee told the CQC there were ‘very unsafe staffing levels on labour ward’, while foetal monitoring was not always completed on time and drugs and observations were late.

Staff also did ‘not always keep detailed records of women’s care and treatment’, while inadequate grading of incidents causing harm meant inspectors ‘were not assured that patient outcomes and the grading of incidents matched the impact or potential impact of harm to the patient or staff member’.

And in a particularly damming note, inspectors said after interviewing staff they failed to find records of two ‘serious incidents’ in the trust’s recording system for such events.

‘Therefore, we did not have assurance that all incidents or serious incidents were investigated, the root cause identified, and that lessons were learnt,’ they said. 

When it came to pain relief in labour, inspectors said staff ‘did not always assess and monitor women regularly to see if they were in pain or give pain relief in a timely way’.

Furthermore, staff did not always treat women with compassion and kindness, respect their privacy and dignity, or take account of their individual needs. 

Trust bosses said they were ‘devastated’ by the findings and vowed to make changes — with 500 more nurses now recruited. 

Its chief executive Kirsten Major said she will do everything she can to support staff to make the necessary improvements. 

‘We are all devastated with the outcome of the inspection because there is not one person within the trust who does not want to do the right thing for our patients and has not worked hard to try and deliver that in exceptional circumstances,’ she said.

‘That is why we are taking it extremely seriously and I will be doing everything in my power to support our staff and make the improvements we need to deliver.’ 

The Ockenden inquiry has made 15 NHS-wide recommendations to help keep mothers and babies safe in England. 

Among these are requirements for increased staffing and training for midwives and clear escalation paths if staff are worried about an expectant mother’s health.

One of the findings of the inquiry was how a fixation on so-called ‘natural births’, vaginal deliveries as opposed to surgical C-sections, prevented mothers from receiving the care they should have, with devastating consequences. 

Police are now investigating 600 cases related to poor care at Shrewsbury and Telford Hospital NHS Trust.

The Royal College of Mid wives estimates maternity services in England are short about 2,500 midwives.