Bradford Royal Infirmary

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that women were protected from abuse and avoidable harm.

At our last inspection we rated this key question as good. We assessed 4 quality statements for this section. At this inspection the rating stays the same.

This meant women were safe and protected from avoidable harm.

The service worked well with women to understand and manage risks or detect and control potential risks in the care environment. Staff knew how to recognise and report abuse and worked well with other agencies. There were improved numbers of midwives and specialist midwives in post. The service had made improvements to the triage process.

Staff told us they continued to work through the outstanding maternity service programme. It was evident there had been a high level of investment, and the methodology had continued to evolve over the last 3 years.

We visited the newly refurbished maternity assessment centre and the antenatal clinic. Staff told us the last phase of the building work was due to be completed. The antenatal day unit refurbishment was underway. The new unit was situated next to the maternity assessment centre with access to both units. We saw improvements to accessible car parking and signage.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We spoke with several women, birthing partners and family relatives who confirmed they had no concerns regarding raising complaints with patient safety or staffing concerns. They felt part of the care planning process and were encouraged and supported to raise concerns.

We saw examples of "we said you did" on display boards within clinical settings. Information showed evidence that staff had listened to patient feedback from “friends and family feedback” and had made appropriate changes to practices as a result.

There was a robust governance process in place where complaints, incidents and risk were reviewed, identifying lessons learnt and action planning.

Senior leaders told us lessons learned were produced by the risk team and sent to every member of staff. Staff confirmed they received information on lessons learned from recent incidents in several ways such as safety bulletins and weekly email updates. Staff said they could attend a weekly multidisciplinary team meeting and gave examples of learning and action taken.

Staff we spoke with said that risks were not overlooked or ignored, and processes were in place to put things right, learn and improve.

Staff told us they had received additional training on accurately recording incidents and grading in line with the national reporting system. We spoke with staff about reporting incidents, they knew what and how to report. We saw incidents were reported by all disciplines of staff at all grades.

We also asked staff about their understanding of Duty of Candour, and they were all able to give us a summary which was in line with Duty of Candour requirements. There was a Duty of Candour policy which was in date and staff could access easily if they needed to.

Senior leaders told us a member of the Quality & Safety Team for maternity conducts a daily review (Monday to Friday) of incidents reported by staff via the incident reporting system. All incidents are triaged, and those that raise concerns are immediately reviewed in greater detail and escalated to the senior leadership team as appropriate. As part of the triage process, each incident is also assigned to a suitable investigator.

Safety incident huddles are held three times a week to briefly review and discuss all reported incidents. All senior leaders are invited to attend. These huddles provide a valuable opportunity to share learning and expertise, ensure appropriate support for staff and service users, and promote awareness and discussion of incidents within the Clinical Service Unit (CSU). Each huddle includes a review of incident grading and determines the appropriate level of investigation, ensuring duty of candour is applied where required.

We saw a range of safety huddles and opportunities in place for learning to be shared. This provided assurance that all staff were able to access learning from incidents. A set of defined safety-related questions are reviewed during the huddle, with responses documented on the safety huddle spreadsheet. In addition to assessing real-time safety and operational needs, the huddle serves as a forum for sharing key updates, safety messages, and critical information across the team.

A Quality and Safety (Q&S) bulletin was produced on a weekly to fortnightly basis and included key learning from recent incidents. The bulletin was distributed via multiple channels: it was emailed to ward managers, shared on the closed Maternity social media platform, and printed copies are displayed on departmental governance boards to ensure wide accessibility and visibility.

The Maternity Safety Event Review Forum (MSERF) is a weekly multidisciplinary team (MDT) meeting where selected incidents are reviewed. These include low or no-harm incidents that raise concern, as well as all incidents classified as being moderate and above.

Each case is assessed using a systems-thinking approach, exploring the difference between "work as imagined" and "work as done," and considering contributory factors, human factors, with an equality and diversity lens. The forum identifies areas of good practice, agrees on learning points and opportunities for improvement, and sets out actions to address any identified issues.

During the review, duty of candour is considered, the final incident grading is confirmed, and a set of equality, diversity, and inclusion (EDI) questions are explored. All agreed actions are recorded on the MSERF action tracker, with designated action owners assigned.

The MDT discussion is documented using the Trust’s Patient Safety Incident Review Framework (PSIRF) template, developed by the Quality & Safety Team In addition, a monthly ‘Moderate and Severe Incident Report’ is produced and presented as a standing agenda item at the monthly Women’s Services Quality & Safety Meeting.

The service runs a monthly perinatal services forum.The perinatal forum is a multi-professional group that includes core membership from the Maternity and Neonatal Voices Partnership (MNVP). The forum focuses on quality improvement (QI) initiatives within the maternity and neonatal service, with an agenda aligned to the five outstanding maternity and neonatal service work streams. The quality & safety team share learning from joint neonatal and maternity cases and provide updates on pathways and guidance that have been revised following incidents and investigations

The service also runs a fortnightly Perinatal Mortality Meeting (PMRT). The role of the panel is to conduct systematic, multidisciplinary, high-quality reviews of the circumstances and care leading up to and surrounding each perinatal death. A member of the quality & safety team and the PMRT midwife attend to ensure that any initial learning from the maternity safety event review forum (MSERF) review is incorporated and discussed within the mortality review. An external peer review process is in place across the local maternity and neonatal system (LMNS) to ensure that all mortality meetings include external membership and benefit from independent peer review. We saw evidence of meeting minutes which highlighted review, action and learning.

Staff told us they attend the monthly speciality governance meeting. This meeting covers learning from safety events, audits, projects, national reports, and ongoing work streams. It fosters a collaborative and supportive environment for discussing and sharing information and insights. The forum also provides an opportunity to share wider Trust-wide learning, quality improvements, and successes both within and beyond the clinical service unit (CSU). Joint meetings are held regularly with other services to promote cross-disciplinary collaboration: twice annually with neonatal services, annually with emergency department (ED) and anaesthetics, and three times a year with the Trusts system partner, Airedale NHS Foundation Trust.

The service was currently developing a quality & safety learning microsite on the Trust intranet to enable staff to access and view presentations. The intranet is continually being enhanced to improve accessibility for clinical staff, particularly regarding learning from incidents.

We saw evidence of incident investigations which showed they had been appropriately investigated and reported. They followed process to report incidents to external partners such as Healthcare Safety Investigation Branch (HSIB) and Maternity and Newborn Safety Investigations (MNSI). Leaders and staff were able to explain immediate actions and learning. A total of 5 cases classified as severe and fatal incidents had been reported between August 2024 and September 2025. Two were classified as severe and 3 as fatal. Of these, 3 met the MNSI referral criteria and appropriate referrals were made. The remaining 2 cases did not meet the criteria.

We reviewed PSIRF (patient safety incident response framework) incidents for the last 12 months. In the last 12-month period from 8 August 2024 to 8 August 2025, the trust reported 7 serious incident notifications.

As part of our review of evidence we further looked at learning from events reported to MNSI (Maternity and Newborn Safety Investigations) and PMRT (Perinatal Mortality Review Tool) investigations. Action plans with specific responsibilities were developed to make sure learning was shared across multi-disciplinary teams and departments.

We reviewed LFPSE (learning from patient safety events) submitted by the trust. In the 12-month period from August 2024 to August 2025, the trust reported 1,722 LFPSE notifications under specialties related to maternity services, with 88% in Midwifery, 9.6% in Obstetrics, and 2.6% in Obstetrics and Gynaecology.

Staff told us they were aware of the multiple channels for freedom to speak up and felt supported by the pastoral midwives. Staff we spoke with told us they felt confident to actively speak up and raise concerns without fear of detriment or reprimand.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There was a maternity assessment centre (MAC) where women could telephone for over the phone advice from a midwife and if required, attend the department for clinical review. Staff used an evidence-based, standardised risk assessment tool for maternity triage.

The Maternity Assessment Centre (MAC) service was available 24 hours per day, 7 days per week. MAC operates on a triage system which prioritises the order in which patients receive on going care. MAC enables all women to be triage assessed and their individual needs identified. This then allows appropriate prioritization to be made. MAC operates on a self-referral system via telephone. Other referrals are made through Community Midwives, General Practitioners (GP’s), Accident and Emergency departments (A&E), ambulance services.

The service’s referral and admission process ensured all essential information about the patient was received to determine if patient’s needs could safely be met. On admission staff clarified medical history, completed a full antenatal check, assessed for emerging or escalating risk and engaged in shared decision making. All information was recorded on the electronic maternity platform.

Care and support was planned and organised with women, together with partners and communities in ways that ensure continuity.

The care, treatment and support women received was planned in collaboration with women, their families, health care partners and care providers. We saw evidence was done in a way that maximised continuity of care throughout the person’s pregnancy pathway as much as possible. The referral and admission processes of the service ensured that all essential information about the patient was received to determine if the patient’s needs could be safely met.

Vulnerable and high-risk women were supported by community midwives who built relationships with them over time, building trusted links within communities. Women were also able to access the maternity assessment unit if they were concerned about their pregnancy at any point.

Staff involved healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Women we spoke with confirmed they had a named midwife throughout their pregnancy and were able to contact them if required.

All women we spoke with were satisfied that their dignity and privacy had been respected.

Women provided positive feedback about having enough information to decide on their care and treatment decisions which included delivery locations and birthing plans.

Women told us that staff asked about their emotional well-being at each antenatal and postnatal appointment.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand what being safe means to them as well as with their partners on the best way to achieve this. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and they made sure they shared concerns quickly and appropriately.

Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

We reviewed safeguard training data that evidenced medical and midwifery staff had completed safeguarding adults and children training levels 1 and 2.

There was an accessible and up to date safeguarding policy in place. This provided staff with guidance about actions to take when they had safeguarding concerns about people.

Staff knew who the safeguarding specialist midwives were and spoke highly about the positive working relationship they had with the maternity safeguarding team.

The service instigates a complex care panel meeting fortnightly to discuss complex safeguarding cases.

The maternity services had developed a fortnightly complex care panel where a multidisciplinary approach is taken to optimise the care pathway for pregnant women with complex needs. The aims of the panel are to recognise the increasing complex needs of women accessing maternity services and developing a pathway of care to maximise good outcomes for mother and baby. The panel supported community midwives offering a space for supervision/awareness in risk assessing and planning complex care. We joined a meeting post inspection which evidenced a multi-disciplinary approach to review decision making, plan of action and agree care moving forward. Safeguarding was central to this panel.

The service works closely with a Specialist Mother and Baby Mental Health Service (SMABS). SMABS is a Bradford District Care Trust service. It aims to help mothers recover from mental health problems and improve their well-being, especially those with a history of severe mental illness. The service is available to all women of childbearing age in Bradford, Airedale, Wharfedale, and Craven, and focused on a whole family approach, supporting not only the mother but also the infant and partner.

Staff told us they run a specialist Perinatal Mental Health clinic twice a month in the antenatal clinic. Women are referred to this clinic if they are at higher risk of experiencing moderate to severe mental health problems in the perinatal period. Care is provided by an obstetrician (pregnancy doctor) with a specialist interest in perinatal mental health and a specialist perinatal mental health midwife. They can make referrals to additional specialised support services. The team work closely with women referred into the service and mental health services to develop a plan of care to support them during pregnancy and the postnatal period.

Staff told us women can self-refer into talking therapies if suffering with anxiety and depression. The service also works closely with a service called Little Minds Matter. Little Minds Matter is a is a Bradford District Care Trust service. This is a specialised parent-infant relationship service working with infants, their families, and associated professional networks during the first 1001 critical days (conception to two years). A dynamic multi-disciplinary team delivers four strands of work to embed early intervention support for Bradford families through direct clinical support, training, consultation, and community engagement.

The service had a perinatal mental health guideline detailing the service provision within the trust and the referral pathways for internal and external management and support. Staff could refer women to the Birch clinic which is the joint obstetric/midwife antenatal clinic for women with severe mental health disorders. Clinics are held on Wednesday afternoons twice a month providing an opportunity for specialist care planning. If a pregnant person had neurodiversity or a mental health diagnosis they could be referred and seen in Birch clinic.

The maternity service’s pathway reflected a commitment to safeguarding, inclusivity, and person-centred care.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

In October 2024, a newly refurbished and expanded Maternity Assessment Centre (MAC) opened. This is a triage facility covering pregnancy from 16 weeks onward, providing a calm environment for mothers, with four-bedded bays, two private single bed bays. There were plans to add two more single-bed bays in 2025.

The service had introduced a telephone triage assessment which was in line with Birmingham symptom specific obstetric triage system (BSOTS) at the last inspection in 2024. This had improved the compliance of triaging women within 15 minutes. We visited the newly refurbished maternity assessment unit and observed triage calls coming into the unit. We spoke with women on the unit at the time of the inspection who had been triaged receiving ongoing clinical assessment and support. Women told us the triage system was mostly efficient; staff were kind and considerate.

The new unit was fit for purpose and met the needs of women and families using the service. The seated waiting area had comfortable seating, the reception desk was situated behind the seated area ensuring staff had clear oversight sight of women for continued observation in the event of deterioration and clinical emergency.

An expanded antenatal clinic had also opened as part of a £15.5m refurbishment project. It included a reception area, 11 clinical examination rooms, and a waiting room for up to 70 people and is part of the Women's and Newborn Unit. We visited the antenatal clinic during the inspection. Feedback from mothers was mostly positive; however, some women said they had experienced long waits to see medical staff and awaiting specific tests. Senior leaders told us some clinics did see high volumes of women. For example, the diabetic clinic, where women are initially screened, risk assessed, specific clinical tests are required which then require consultant follow up and review.

The service had a maternity dashboard to monitor clinical performance and governance. The dashboard monitored themes and trends to inform decision making and improvements. Some areas of the dashboard were RAG (red, amber, green) rated in line with national and regional expectations. The service had developed several dashboards as part of an evolving improvement project led by the Digital Midwife.

Leaders told us the RAG-rated dashboard, had been in use for several years. However, most data was now sourced from the digital dashboard, which automatically extracts information from the Electronic Patient Record (EPR) every 24 hours.

Senior leaders informed us they had added additional fields to the risk assessment tool to identify potential additional risk factors faced by mothers with protected characteristics including ethnicity and those living in deprived circumstances or with disabilities for example a question had been added surrounding neuro divergence. Work was ongoing with regard the plan to streamline the digital pathway.

Staff completed risk assessments for each woman on admission or arrival, using a recognised tool, and reviewed this regularly, including after any incident. We reviewed 5 care records and saw risk assessments were completed at booking appointment and updated regularly. We saw risk assessments identified key factors such as age and health conditions.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.