Improving maternity services

September 2023

We have responded to Donna Ockenden’s letters of April and August 2023 to outline posituive action taken against the feedback that has been provided to the Trust.  You can read the full response from Anthony May our Chief Executive in the letter below:

 

Dear Donna,

Re: Independent Maternity Review – Nottingham University Hospitals NHS Trust
Thank you for meeting with us on 14 April and 21 June, and for your subsequent follow up letters dated 20 April, and 8 August 2023. In our most recent meeting, we promised that we would formally write to outline how we have responded to the points you raised in the two letters above, both of which are published on our website (20 April 2023, and 8 August 2023). The responses below also reflect the verbal feedback provided by Michelle Rhodes our Chief Nurse in our meeting on Thursday 31 August.

As always, we welcome the opportunity to hear your feedback on a regular basis, as it allows us to take action. We also are pleased to have been able to use the meetings to update you verbally on the work of the Maternity Improvement Programme at NUH, including on some of the feedback detailed below.

Points addressed in the correspondence dated 20 April 2023
You expressed to us that the feedback you had received from local Black and Asian women was that mistrust of the Trust has deepened and that our communication and relationships with them have progressively worsened. This included language and communication’ failures with women saying they did not feel heard or seen:

• Concerns from maternity staff of a proposal to reduce Urdu language appointments accompanied by an interpreter from 30 minutes to 20 minutes.
• That women had raised with you a lack of interpreting services within the Trust leading to women for whom English is not their spoken language having to make decisions without informed consent.
• A lack of translated written materials into languages such as Urdu, which was leading impacted women’s ability to make informed choices about their care.

In the letter, you also described ‘a failure to appreciate cultural sensitivities’ including occasions when a female sonographer has not been available for the care of Muslim women who had requested one.

We have thanked you for this important feedback and taken significant action since the meeting on 14 April to address the issues identified. Colleagues in our Transformation team presented some of the activity to you in our subsequent meetings on 21 June and 31 August. Progress made since April includes:
• A new taskforce of midwives, doctors, researchers, advocates and representatives from Black, Asian and minority ethnic staff and families has been immediately established.
• The proposed change to the length of appointments was not introduced.
• Information on the maternity pages of our website is accessible and available in different languages.
• Letters inviting women for scans now include the choice of a female sonographer if preferred.
• Forthcoming events in the service with a focus on inclusion include a ‘Who’s Shoes’ learning event aimed at black and ethnic minority service users in maternity, and a Maternity Staff Summit in October as a celebration of Black History Month.
• Our lead midwives are representatives on the local LMNS Maternity Interpreting Services working group.
• We are piloting a 24-hour Languages on Demand Video Interpreting service in our labour suites from 11 September 2023, which will allow live consultations or pre-booked appointments. This service includes Urdu as one of the languages.

Points addressed in the correspondence dated 8 August 2023
You told us that women told you they were still told to ‘break their fast’ for some blood tests without flexibility for early or later blood tests during the month of Ramadan.

This feedback has been shared with our anti-natal services Matron, and various actions are being taken to address the issue, including; engagement with a local Muslim women’s group for education and awareness; a date has been set for January 2024 in order for us to raise awareness with staff and to plan proactive communication with women on this issue; and we are planning a visit to Bradford’s anti-natal services to learn from their approach.

You shared with us feedback that women you had spoken to had repeatedly told they are not in labour ‘it’s Braxton Hicks’, when contacting the unit, and that other women are told they could not be in labour and to stay at home ‘if they can ‘talk on the phone.’ You identified a theme of women not being believed that they were in labour.

This information has been shared with the matron and managers for Maternity and Labour (MAL) and has been added to the agenda for the next MAL team meeting for further discussion and awareness. We are improving our communications channels within the service for sharing learning and feedback such as this, including a new MAL email list including CMW, NHSP and triage staff, as well as a new learning whiteboard for Maternity and Labour. We are also working to separate the latent phase of labour guideline for staff from the overall intrapartum guideline to make it easier of staff to access the right information. We have also checked our complaints records for any additional intelligence or learning, although it has not been identified as a theme in our records.

You identified “repeated examples of manual removal of placentas’ being undertaken without appropriate anaesthesia in a labour ward room rather than in a theatre, often with only gas and air.” Our maternity guideline sets out that manual removal of placentas should be undertaken in theatre with consent and adequate analgesia. We have reviewed all of these procedures which have been recorded on Badgernet since the beginning of 2023, and 97.5% comply with the guidance.

The cases that were not managed in accordance with guidance are being managed as incidents to understand what happened and to identify opportunities for learning.
Parents had fed back to you that the maternity team were using genetic testing as a ‘first line’ of enquiry, before any governance investigation or enquiry following a baby being born in unexpectedly poor condition.

We have investigated this feedback to better understand any underlying concerns. For diagnosis of Hypoxic-ischemic encephalopathy (HIE), we follow standard criteria which are established nationally, and are in our neonatal HIE guidelines.

Genetic testing is not done routinely at NUH, and where there is clinical rationale to follow a HIE test, it must be discussed with the parents first. Genetic testing is only carried out in circumstances where the clinical presentation doesn’t quite fit and there is a possibility of other factors (family history for example), or no discernible underlying cause for hypoxia. Of more than 200 referrals for R14, there are only two instances where HIE is mentioned, and if a baby was referred for testing with just HIE, the guidance if for the test to be rejected.

R14 genetic tests are only carried out under the direction of the genetics expertise.
Parents reported to you that they had been told by the maternity team that their notes had been ‘lost’ by the Trust but the Review team have them (electronically) meaning they cannot be lost.

We have requested more specific information on these cases so that we can review and respond on the individuals involved.

We hope that the above responses given you assurance that we are taking the feedback that we receive from your team, mothers, and our colleagues seriously, and that we remain committed to taking action to resolve issues where they are identified.

You will also be aware that since we met, the CQC have published their latest reports for NUH, which has upgraded maternity services at City Hospitals and Queen’s Medical Centre to Requires Improvement from Inadequate. We know that we have improvements to make but are pleased that the regulator has recognised the progress that has bene made so far.
In their report, the CQC found that “Staff in both maternity services were kind and understood the personal, cultural, religious, and social needs of each person and showed understanding and a non-judgmental attitude when caring for or discussing people with mental health needs.”
Nottingham University Hospitals remains fully committed to the Independent Maternity Review, and we look forward to meeting with you again shortly.

Yours sincerely

Anthony May OBE DL
Chief Executive

During their inspection, the CQC saw a number of improvements in areas where concerns had previously been raised: 

• Previously, women had not been listened to regarding their care in maternity. At this inspection, the CQC observed staff who were skilled in communicating with women and their families. They found that all the interactions between staff, women and their families were caring, positive and informative. Women were listened to and involved in their care. During their inspection, the CQC noted that women gave ‘overwhelmingly positive’ feedback about the service and results from the latest national maternity survey showed that women giving birth in 2022 had a better experience that when giving birth in 2021. Feedback from women and families in the Friends and Family Test (June 2023) shows that 96% of respondents rate their experience as good or very good. 

• Significant improvements were seen in the triage unit and day assessment unit. This is described by the CQC as a ‘key achievement’ since the last inspection with 96% of all pregnant women being seen within 15 minutes of arrival in the triage unit. Staff especially demonstrated kindness towards the women attending and worked to make sure women did not stay longer than they needed to. Cardiotocography (CTG) monitoring for women, which was previously an area of concern, was now completed appropriately and was documented in line with national guidance. Staff said they felt confident in reviewing the traces and escalating when required.   

• Staffing concerns had improved with the CQC noting that maternity services provided enough staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. They also found that managers regularly reviewed and adjusted staffing levels and skill mix. The CQC noted the focus on recruiting and retaining midwives, including the introduction of retention lead to oversee recruitment and retention. This included plans to improve staffing levels through a number of schemes, including international recruitment, return to practice, advanced clinical practice, and an increase in student midwifery university placements.  

• At the last well-led inspection, the CQC had concerns around the values and behaviours of some of the leadership of the Trust. During this inspection, the CQC noted that the executive team consistently led with integrity and were open and honest in their approach. Some staff still didn’t always feel able to raise concerns without fear of retribution, but leaders at the Trust were aware of this and were working to create a workplace that is free from bullying, harassment, racism, and discrimination. The CQC witnessed examples of where appropriate learning and action had been taken because of concerns raised. CQC inspectors found that most staff felt positive and proud to work in the organisation. 

The CQC identified areas where the Trust needs to focus on to improve further, including:  

• The Trust must improve processes around Duty of Candour with patients to inform them of incidents   

• Following appropriate guidance in the proper and safe storage and administration of medicines  

• Ensuring that expressed breast milk is stored safely and in line with national guidance.  

• We must improve to make sure staff consistently carry out risk assessments to keep women, their babies and staff safe from potential abuse.  In addition, all staff need to receive mandatory training to enable them to recognise and report abuse to protect women and babies.   

• The trust should ensure arrangements for identifying risks, issues and mitigating actions are embedded  

• We should continue to strengthen a culture where staff have a voice that counts and is valued by leaders and managers by consistently tackling behaviour and actions in a timely way to aid learning and improvement.  

In addition to the findings from the CQC report, there is a whole host of work and improvements taking place across our services. We have established a dedicated Maternity Oversight Committee to scrutinise our Maternity Improvement Plan and provide regular reports to our Board, to provide the public with an opportunity to track our progress. 

Alongside this, we are working with Donna Ockenden in support of her independent review of our maternity services, and Nottinghamshire Police, and have committed to an honest and transparent relationship with the families whose lives have been affected by our maternity failings. 

• Four key areas of improvements to focus on until March 2023 identified:
  • Governance: This includes addressing the backlog of serious incidents
  •  Postnatal care: How we can make our discharge processes much smoother and quicker and focussing on care
• Communications and Engagement: How we can continue to improve our communications and engagement with our communities and staff
  • BadgerNet: Continuing to develop the system.
• Signed Memorandum of Understanding with Birmingham Women’s and Children’s Hospital
• International recruitment continues
• New Heads of Midwifery join the service
• We are offering our registered nurses the opportunity to undertake a Master's Degree to convert to midwifery training. We have 10 people starting that course

*Continued focus on recruitment and retention, including recruiting internationally for roles including midwives, doctors and support roles.

Donna Ockenden independent review update

In September 2022, Donna Ockenden began her independent review of maternity services at our hospitals.

As part of the review process, Donna and her team share key findings with us and NHS England on a regular basis. This feedback supports the continuous learning and improvement of maternity care at NUH and is included into our existing Maternity Improvement Programme.

At the most recent meeting held on 21 June 2023, Donna and her team met with Chief Executive Anthony May, Chief Nurse Michelle Rhodes and Medical Director Dr Keith Girling where she provided feedback from meetings that she is continuing to hold with mothers and families taking part in the review.

We are committed to sharing that feedback in an open and transparent way as we continue to learn and improve.

In the meeting, Donna fed back about the positive experience of one mother who explained how one of our midwives had ‘turned her life around’ using her knowledge and support to advocate for the mother through some very complex circumstances. Feedback included:

• Local families, who may be ‘hard to reach’, do not always feel heard and there is a lack of continuity with information sharing, particularly in Urdu clinics.
• Concerns have been relayed from some maternity staff about a proposal to change the length of clinic time accompanied by an Urdu language interpreter.
• Women have raised a lack of availability of interpreting services within the Trust. There have been some issues with telephone provision for interpretation.
• The review team have been advised that there is no written information in Urdu.
• Local women have reported instances of male sonographers being allocated to the care of Muslim women. There have been incidences where female sonographers have not been available.

We were also able to present Donna and the Review team with an update from our Inclusivity Maternity Taskforce which has been set up in response previous feedback around how we engage with black and ethnic minority services users and is working to improve our services in this area.

Donna also fed back on areas that we need to continue improving:

• Our interpretation and translation services were described as ‘hit and miss’ and we need to do more to help women who do not speak English as a first language
• We should be planning for extra provision for blood testing during Ramadan so that we are not having to ask women to break their fast during this period
• We need to better work with women who contact our services and believe they are in labour
• Women are providing the review team with repeated examples of ‘manual removal of placentas’ being undertaken without appropriate anaesthesia in a labour ward room rather than in a theatre
• Challenges made about the use of genetic testing as a first line of enquiry following a baby being born in unexpectedly poor condition, feedback which we will audit and review
• Parents have reported being informed that their notes have been lost, although we have bene able to provide them to the review team.

Donna followed up in writing with a letter addressed to Chief Executive Anthony May on 8 August. You can read the letter here - 08.08.23 DO letter to Anthony May.pdf [pdf] 547KB

Michelle Rhodes, Chief Nurse, said: “We are grateful for the continued and regular feedback on our services from Donna Ockenden.  The format of the meetings enables us to act swiftly on the information we are given to improve services for our women and families rather than waiting for the publication of the review to act. 

“We know that more work needs to be done in a number of areas and we are taking forward the most recent feedback from Donna alongside the continuing Maternity Improvement Programme.

“Our teams are absolutely committed to improving services, and we are proud that the work of the taskforce was recognised for making progress in a number of areas with black and minority ethnic groups, as well as the important work midwives are leading with the homeless and asylum seekers.  It is also gratifying and humbling to hear the individual testimony of the difference one of our midwives made with a mother, which is the level of care that we all should aspire to.

“Women and families can be assured that the feedback and learning that is shared with us throughout the review is used to make improvements to our maternity services immediately.”

Further information about the review can be found here.

Scope of the Independent Review

Since the most recent meeting with Donna Ockenden it has been agreed that the terms of reference for the Independent Maternity Review are changing to an ‘opt out’ basis for women and families identified as being within scope rather than the previous ‘opt in’ arrangement. This means that women and families will automatically be included in the review unless they contact the review team to say no; previously it was the other way around.

As the subject of the review, this was not our decision to make, but one that NHS England as the commissioners have taken. This will mean that more people will take part in the Review, and may change the timescales involved.

We know how important this review is for the families, our staff and all our communities and we will continue to work with NHS England and the independent review team to ensure that everyone who wants to can share their experiences and have their say.”

How we are taking action to improve our maternity services

In September 2022, Donna Ockenden began her independent review of maternity services at our hospitals.

As part of the review process, Donna and her team share key findings with us and NHS England on a quarterly basis. This feedback supports the continuous learning and improvement of maternity care at NUH and is included into our existing maternity improvement programme.

At a meeting held on 14 April, Donna and her team met with Chief Executive Anthony May, Chief Nurse Michelle Rhodes and Medical Director Dr Keith Girling, where she provided feedback that:

• Local families, who may be ‘hard to reach’, do not always feel heard and there is a lack of continuity with information sharing, particularly in Urdu clinics.
• Concerns have been relayed from some maternity staff about a proposal to change the length of clinic time accompanied by an Urdu language interpreter.
• Women have raised a lack of availability of interpreting services within the Trust. There have been some issues with telephone provision for interpretation.
• The review team have been advised that there is no written information in Urdu.
• Local women have reported instances of male sonographers being allocated to the care of Muslim women. There have been incidences where female sonographers have not been available.

Donna followed up in writing with a letter addressed to Chief Executive Anthony May on 20 April. You can read the letter here -  Letter to Anthony May. 372KB

Michelle Rhodes, Chief Nurse, said: “We know more must be done to ensure the voices of women from all the communities we serve are heard, and we welcome feedback from Donna Ockenden and her team.

“Women and families can be assured that the feedback and learning that is shared with us throughout the review is used to make improvements to our maternity services immediately.”

A new taskforce of midwives, doctors, researchers, advocates and representatives from Black, Asian and minority ethnic staff and families is working to immediately address areas highlighted by Donna Ockenden to ensure equality of opportunities, and inclusive and responsive services for all women and families. This includes:

• The length of clinic times which use interpreters in the community will not change.
• Information available for women on our website, including leaflets are accessible and available in different languages.
• Letters inviting women for scans now include the choice of a female sonographer if preferred.
• Addressing health inequalities as a system across the Nottingham and Nottinghamshire Local Maternity and Neonatal System (LMNS), including access to cultural competency training.
• Reviewing data on clinical outcomes through a health inequalities lens to provide more focused improvement actions.
• In the coming weeks our midwives, led by our Director of Midwifery, will be working with community groups across Nottingham and Nottinghamshire, to listen to their experiences and use this additional feedback to make improvements wherever we possibly can.

Michelle added: “We want to reassure women and families using our services that the teams caring for them are totally committed to providing the safest and best experience possible and are available to answer any questions they might  have.

“We continue to encourage people who have significant or serious concerns about their maternity care to contact the review team. We are also encouraging current and former staff who work directly in or closely with our maternity services, to come forward and engage with the review.”

Further information about the review can be found here.

Dear families, 

We have been working hard to make improvements across our maternity services. With the help of your feedback, support from colleagues across healthcare, local councillors and MPs, and of course the dedication of our staff, we have made a number of improvements.

At the start of March 2022 we welcomed inspectors from our regulators – the Care Quality Commission (CQC) – back into our services, and they published their report which can be read here. They have noted a number of these improvements, however, they also picked up on areas of concern.

We realise this may be hard for you to see if you are planning to have your baby in our care, and it is certainly disappointing for our staff. We know that real improvement takes time. We are committed to improving the pace at which we make the changes needed, while ensuring that any improvements are sustainable.

One of the biggest challenges we face is staffing. Like our neighbouring hospitals, the national shortage of midwives is having a particular impact. We want to reassure you that we are making every effort to recruit as many midwives, doctors and support staff to our team as we can.

However, your safety and our ability to provide high quality care are our top priorities so we cannot wait for additional staff before we make changes. So, we are also thinking about how we do things differently to keep you and your families as safe as possible in our care. For example, you may see nurses in our postnatal areas to help support your recovery after labour. We are offering apprenticeships to our maternity support workers, to enhance the skills they hold to help care for our families, and we may reduce the capacity of our wards to ensure those in our care have the support they need.

Another big change, which we’ve made since the CQC inspection, was to separate our day assessment and triage areas in our hospital. We’re pleased to say that now when you come into our hospitals because of a concern you will not be seen alongside those with routine appointments.

Inspectors rated our caring as ‘good’ and they told us that we also provide good treatment. They highlighted improvements in our management of safety incidents, and said we were focused on the needs of women and families receiving care.

They also highlighted some areas they deemed to be outstanding, saying our specialist midwives went above and beyond for the women they cared for, and some of our scenario training to learn from incidents was also outstanding.

Keeping patients safe and providing high quality care are our top priorities, and we are increasing the pace with which we address the concerns in this report.

We are proud of our teams for the improvements they have put in place, but we realise we have more to do and we are committed to continuing to work with local families and healthcare partners to make the changes required.

You can read the full report on the  Care Quality Commission website 

If you have any concerns or questions please speak to your midwife.

Best wishes,

Sharon Wallis, Director of Midwifery.

• Invested in and rolled out equipment to measure jaundice in babies
• New care plan launched for babies who have low blood sugar levels
• Invested in and rolled out more than 50 new machines to trace babies heartbeats (CTG machines)
• CQC inspection
• Nottingham and Nottingham Local Maternity and Neo-natal System (LMNS) awarded £1.7 million in funding to support the digital improvements at Nottingham University Hospitals NHS Trust
• Created Maternity Apprenticeship roles to enhance the skills of our staff
• We separated our Triage and Day Assessment Unit areas. This means that people who need emergency and routine care will be seen in separate areas
• Opened a Rainbow Clinic to support those who have lost a baby
• Introduced Birmingham Symptom- specific Obstetric Triage System (BSOTS) in our triage service. This is a system similar to the one used in A&E where people are prioritised based on how urgent their medical needs are
• Independent Maternity Review starts, led by Donna Ockenden
• We expanded our team to support people with feeding their baby, this saw us welcome five support workers to work alongside our Infant Feeding Lead across the QMC and City Hospital
• Launched BadgerNet - an online system which makes it easier to share and access information
• Welcomed nurses onto areas such as the postnatal areas to help support people’s recovery after labour.

Maternity Triage Opened April 2022

In April 2022, our Triage Service became a stand alone service providing emergency care in pregnancy.  We aim to see women within 15 minutes of arrival and since April over 90% of our women and families are seen in triage within 15 minutes.

Maternity Advice Line 

In response to your feedback, we now have a team of midwives providing support for you when you need it, 24 hours a day, every day of the year. If you have any concerns during your pregnancy or after baby arrives, you can now talk to our friendly midwives on 0115 9709777.

BadgerNotes rolled out

Parents-to-be across Nottinghamshire can access their pregnancy notes online via an app called Badger Notes. 

The move will provide families with greater access to their pregnancy records and information via their smart phone, PC or tablet, at any time of the day or night. The new digital record system has a whole host of features, enabling people to view extracts of information from their pregnancy record in real time and log key pregnancy events. Read more here.

• Work continues on updating and revising information such as guidelines and internal processes
• Invested in new IT equipment (laptops, PCs and phones) for staff working in the community and upgraded IT systems and processes
• Programme of work starts to improve outcomes for women and families who experience post-partum haemorrhage
• CQC inspection
• Invested in equipment and ongoing enhanced training to monitor a baby’s heartbeat (fetal monitoring) - this is in additional to welcoming staff focussing on fetal monitoring
• An app called Birthrate+ was rolled out on our postnatal wards to support safe staffing
• Revised serious incident process so that Rapid Reviews on all incidents which are classed as moderate and above, take place within 24 hours
• Digital Programme Board established to look at how we can address some of the immediate digital issues we had in the service
• New jaundice pathway rolled out in the community
• New induction of labour lounge and triage area opens
• Maternity Advice Line launched so our communities can speak to a dedicated midwife about any concerns before or after birth. The phone number is free to call and open 24/7
• Increased consultant cover across our hospitals, to ensure we have more doctors available.

2020

• A Maternity Transformation Board is established
• CQC inspection