Queen's Hospital

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked women’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. The service was in breach of safe care and treatment, in relation to the management of incidents, embedding of learning, risk management within triage and staffing. At this assessment the rating remained unchanged, and the service remains in breach of legal regulation under safe care and treatment. This is in relation to the timely closure of incidents and the management of medicine prescription charts, which meant there were still aspects of the service that were not always safe.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. Lessons were learnt to continually identify and embed good practice. However, incidents were not always reviewed, addressed, and closed in line with trust targets.

Staff we spoke with knew what incidents to report, how to report them and felt encouraged to do so. Staff understood the duty of candour and could give examples of times they had been open and transparent with women and their families when things went wrong.

All reported incidents were reviewed daily, Monday to Friday during a maternity safety huddle. During these huddles, the level of harm and the appropriate investigation pathway were discussed and agreed upon by the multidisciplinary team. The investigation pathways included, after action reviews (AAR), patient safety incident investigations (PSII), and referrals to the maternity and newborn safety investigations (MNSI) programme.

Staff reported they received individual feedback following incidents and that learning was shared with the wider team. We observed learning from incidents being discussed at various handovers, safety huddles and team meetings.

As of 1 September 2025, the service had 43 incidents that had remained open for over 60 days, this was not an improvement from the last assessment. The service reported each of these incidents had a named lead allocated and they were under investigation through appropriate pathways. 15 of these incidents were currently undergoing a PSII, with the oldest being opened for 690 days against a closure timeframe of 6 months. 16 incidents were undergoing an AAR, with the oldest being opened for 599 days against a closure timeframe of 42 days. The remaining 12 incidents were undergoing multidisciplinary reviews or perinatal mortality reviews using the mothers and babies: reducing risk through audits and confidential enquiries (MBRRACE- UK) tool. Prompt incident investigation is a cornerstone of safe, transparent, and responsive healthcare delivery. The service did not identify why closure of incidents had been delayed.

The service held maternity serious incident group meetings to discuss incidents and identify learning. Although the frequency of these meetings was not specified by the service, we reviewed 3 meeting minutes from August 2025. These showed meetings were well attended, comprehensive and clearly identified learning and actions in response to incidents.

The service made changes in response to feedback collated from external stakeholders and women using the service. The service had connectivity issues affecting the availability of translation services. In response to this and to the feedback from stakeholders, the service introduced the bilingual maternity support worker (MSW) pilot. This involved pairing a woman, at the time of admission, and an MSW who shared the same language, to ensure women’s translation needs were met even in the absence of the translation service. The service was working to improve the connectivity issues, and this was highlighted on their risk register.

Another example of learning was how the trust worked in collaboration with other trusts within the Local Maternity and Neonatal System (LMNS). The LMNS is a partnership between the service and relevant stakeholders within North East London. The system worked to develop and transform maternity services in response to local needs and national recommendations. The LMNS held monthly meetings, which were well attended, comprehensive and prompted shared learning. Through collaborative working it was identified that the trusts within the LMNS were below the national target of 85% for ‘right place of birth’ metric. In response to this a review was undertaken, the contributing factors were identified and proposed actions have been developed.

The service was working towards maintaining safe systems of care and sustaining continuity of care, including when women moved between different areas within the service.

Women could not always access the service in a timely manner. Women could self-refer to the service when they became pregnant; however, women did not always have their initial midwife appointment by 10 weeks gestation in line with national institute for health and care excellence (NICE) guidelines. The service aimed to book pregnant women in by 9 weeks 6 days gestation but consistently did not meet the local target of 70%. Compliance was 61% in May, 64% in June and 63% in July 2025. Late access to antenatal care contributes to higher mortality and morbidity rates, especially among ethnic minority women in deprived areas. The service did not identify actions to improve these figures.

The service had a telephone triage line and a face-to-face triage, which most women were initially assessed through before admission. The telephone triage line was staffed by a dedicated core team, in a private area in line with the Royal College of Obstetricians and Gynaecologists (RCOG): Maternity Triage, Good Practice Paper. This was an improvement from the previous assessment.

During the assessment, the triage area was fully staffed and had an assigned dedicated doctor along with a consultant who had oversight. This was an improvement from the previous assessment. The service used a formalised triage tool to assess women on arrival. The triage tool was used to assess how quickly women presenting with pregnancy-related concerns should be seen, based on their clinical need. Staff used a red, amber, green (RAG) rating system to prioritise care. According to the tool and local policy, women should be seen by a midwife within 15 minutes of arrival, and a RAG rating should be allocated based on their presentation. Each colour identified how soon women should be reviewed by a doctor or midwife as required. The service provided audit data for May to July 2025. Compliance for the initial midwife check was 83% in May, 86% in June, and 89% in July 2025. Compliance for doctor reviews was 76% in May, 81% in June and 83% in July 2025. The service did not identify a target compliance rate; however, the figures showed a sustained improvement from the previous assessment.

Access and flow throughout the service had improved since the last assessment. This was due to the introduction of a flow matron, flow coordinators and a discharge coordinator. The service reported that a flow coordinator was allocated on every shift, they managed staffing, flow, and acuity concerns. Staff we spoke with reported there were still episodes of delays in transferring women, however, the introduction of these roles had greatly reduced delays. The service remained fully operational and did not close to the public at any point between the months of July 2024 and July 2025.

The maternity unit had 2 obstetric theatres; however, the service reported that there was a risk that the current theatre capacity might not be sufficient for future demand. The service reported an increased need for elective and emergency caesarean sections (CS) which corresponded with rising national CS rates and a more complex pregnant population. This increased the risk of delays, placed pressure on the elective CS and emergency team, and negatively affected women’s experience of care. Due to the financial cost of an additional theatre the trust invested in additional elective obstetric ‘twilight sessions’ during the week to better align capacity with demand and improve patient safety.

Handovers and safety huddles across the unit involved all relevant members of the multidisciplinary team. Shift changes and handovers included all necessary key information to keep women and babies safe.

Women’s notes were comprehensive and stored securely; however, staff reported they could not always access them easily due to the mixture of paper and electronic notes. This also affected the extraction of information for external submissions and audits. The service reported there were delays in procuring a new electronic patient record (EPR) system. As a mitigation the service aimed to maximise use of the existing electronic system until a new end-to-end EPR system could be procured. This was highlighted on the risk register.

The service worked well with women and healthcare partners to understand what being safe meant to them and how to achieve that.

All staff received safeguarding training specific for their role on how to recognise and report abuse; however, medical staff did not meet the trust target of 90%. The service provided midwifery and medical staff with comprehensive level 3 safeguarding training for children and adults. At the time of the assessment, the overall compliance rate for midwifery staff was 92%, which exceeded the trust target of 90%. The overall compliance rate for medical staff was 84% which did not meet the trust target of 90% and was a reduction since the last assessment. The service reported that the reduced compliance rate was due to industrial action, and they were actively managing non-compliance.

The service had a named safeguarding midwife and 2 deputy safeguarding midwives. Staff we spoke with were aware of the safeguarding team and how to contact them.

The service effectively supported staff in identifying and addressing safeguarding concerns. Safeguarding processes included recognising the needs of individuals with protected characteristics under the Equality Act 2010 and ensuring a non-discriminatory approach to care. Staff knew how to make safeguarding referrals and liaised with other agencies to protect vulnerable adults and children. The service also worked in collaboration with partners such as independent domestic violence advisor (IDVA) to protect women and babies.

Safeguarding concerns were appropriately discussed during handovers, ensuring staff were aware of any potential risks and the actions required to mitigate them. Safeguarding information was accessible to all appropriate staff via an electronic patient record system to aid confidentiality. However, confidentiality of women’s information was not always maintained. In some clinical areas, whiteboards displaying women’s details were not kept confidential. In response, the trust took immediate action by ordering new whiteboards that had features to maintain confidentiality.

The service had an infant and child abduction response policy and a baby abduction avoidance standard operating procedure. The last baby abduction drill took place in March 2025 and learning was identified; however, it was unclear whether the simulated abduction attempt had been successful.

The service worked with women to understand and manage risks.

Staff communicated with women in a way that helped them understand their care and treatment. They also found effective ways to support women with additional communication needs. We observed posters signposting women and their families to a maternity information ‘Padlet’ which provided translated information leaflets in a range of languages. These leaflets included information on induction of labour, labour, and breastfeeding. Women we spoke with felt involved in their care and that clinicians explained care and treatment options well.

Staff assessed whether each woman and birthing person was high or low risk at booking and reviewed this at each antenatal appointment. This was done to ensure women received the appropriate care. Staff gave women and those close to them help, emotional support and advice when they needed it. Staff also made sure women living with mental health conditions and learning disabilities received the care needed to meet all their needs. The service had 24-hour access to mental health liaison and specialist mental health support.

The service also worked with PETAL support to provide professional counselling for women and families who had experienced late miscarriages, stillbirths or terminations. Feedback from women was overwhelmingly positive and allowed women and their families to think positively about their future.

Staff used a nationally recognised tool to identify women at risk of deterioration; the service used a maternity early warning score (MEWS) chart to document women’s observations. MEWS charts we reviewed during the assessment were completed, scored and escalated appropriately if required. Audit data provided by the trust showed 99% compliance between the months of June and August 2025.

When babies were born, staff completed newborn risk assessments using recognised tools which they reviewed regularly. Staff risk assessed each newborn at birth to identify if they required regular observations. Staff then used neonatal early warning trigger and track (NEWTT2) charts to document neonatal observations for babies who required it. NEWTT2 charts were completed, scored, and escalated appropriately when required. The service did not provide audit data for NEWTT2 charts, which meant we were unsure if this audit was being completed.

Staff completed venous thromboembolism (VTE) risk assessments in the records of the women whose notes we reviewed during the onsite visit. Audit data provided by the trust showed 99% compliance between the months of June and August 2025.

During labour, high-risk women were monitored using a cardiotocograph (CTG), a device used to monitor fetal heart rate and uterine contractions. According to NICE guidelines, CTG traces during woman’s labour, should be reviewed hourly by two clinicians (a process known as a ‘fresh eyes’ review). This is to ensure the baby is safe to continue with labour. Audit data showed 87% compliance in April, 89% in May and 91% June 2025. The service did not set a trust target for compliance with the ‘fresh eyes’ reviews however, we saw evidence of initiatives to improve compliance such as a monthly fetal surveillance newsletter and weekly CTG huddles to support learning.

The service detected and controlled potential risks in the care environment. However, they did not always make sure facilities were in line with national recommendation and that consumables were in date.

The maternity services at the hospital consisted of an antenatal clinic, obstetric day unit, triage, birth centre, labour ward and maternity wards. The unit was open 24-hours a day, 7 days a week and was fully secure with an entry and exit system monitored by ward clerks, maternity staff, or security. This was an improvement from the last assessment. During this assessment, entry to all areas within the service was monitored appropriately by staff, and staff challenged inspectors and visitors to prevent tailgating and unauthorised visitors.

During the assessment the maternity unit was undergoing annual refurbishment, which meant both obstetric theatres were closed for maintenance for a week. As a result, all obstetric theatre cases were carried out in the main theatre which was a 3-minute walk from maternity. This also meant all the stock and equipment were stored outside of the theatre in the corridor. This was escalated with the service, and they assured us that the stock was not normally stored there when the obstetric theatre was operational.

The service carried out ligature risk assessments of the environment in line with NHS England National Patient Safety Alert/2020/001/NHSPS. We did not observe any ligature risks onsite; this was also an improvement from the last assessment.

The service had facilities to support the needs of women and their families; however, this was not always in line with national recommendations. A bereavement room was available in the event of fetal loss, but it was not soundproof and was located next to a delivery room. This did not meet the national bereavement pathway recommendations which recommends women should have dedicated, soundproofed bereavement rooms or suites to offer parents complete privacy and comfort. This had been identified on the risk register and the service was working to reduce this risk. As a mitigation, efforts were made to avoid placing women in labour in the adjacent delivery room.

The service had enough suitable equipment to safely care for women and babies. This included cardiotocographs (CTG), sonicaids, and observation machines. However, we found out of date consumables in clinical areas across the unit, this included blood bottles, resuscitation face masks and flexible yankauers. This was escalated to the midwife in charge, and the items were removed from the clinical area.

Staff had access to adequate emergency and safety equipment and carried out daily checks on them. Emergency equipment included neonatal resuscitaires, adult resuscitation trolleys, and pre-eclampsia trolleys. Equipment checks were completed daily.

Women could reach call bells, and we observed staff responding quickly when they were called. Staff disposed of clinical waste safely; we observed sharps bins being filled within a safe limit and clinical and domestic waste being segregated and labelled correctly.

The service made sure there were enough qualified, skilled and experienced staff and they worked together to provide safe care that met women’s individual needs.

The service had enough midwifery and medical staff to keep women and babies safe. During the assessment the numbers of midwives, maternity support workers, and medical staff matched the planned staffing levels in all areas, except the antenatal ward. However, acuity on the labour ward allowed a midwife to be redeployed to provide cover. The service had a good skill mix of medical staff on each shift and reviewed this regularly. The service reported that an obstetric and anaesthetic consultant were on call during evenings and weekends.

The overall shift fill rate for all staff was 98% in May, 97% in June and 93% in July 2025. The overall vacancy rate for staff was 4% in May, 8% in June and 9% in July. The increase was due to an increase in the establishment budget in June which the service was currently recruiting into. The overall sickness rate for midwifery and medical staff was stable at 4.3% in April, 4.1% in May and 4.6% in June 2025. The service did not provide information on the trust targets for fill rates, vacancies or sickness.

The service reported that they used regular bank and agency midwives who were familiar with the service and made sure all bank, agency, and locum staff received a full induction to the service

The service had a flow coordinator midwife on every shift. Flow coordinators were supernumerary and had oversight of the staffing, acuity, and capacity within the unit. They reviewed and adjusted staffing levels and skill mix daily according to the needs of women.

The service used the operational pressures escalation level (OPEL) framework to measure operational pressures. They also used the Birthrate Plus acuity tool to calculate the number of midwives needed on the maternity unit. Midwives in charge carried out the calculation every 4 hours in intrapartum areas of the unit and every 6 hours on the maternity ward. The most recent midwifery workforce exercise by Birthrate Plus took place in December 2024. In response to the findings the trust invested in the increase in clinical staffing by 38.85 WTE as recommended by the Birthrate Plus tool. The trust also invested into medical staffing, particularly in triage.

The service had a daily safety huddle, with the option of organising additional huddles if the acuity was high. The safety huddle was multidisciplinary and was coordinated by the matron for the maternity ward. The safety huddle covered topics such as staffing, acuity levels, safeguarding and recent incidents.

The service monitored maternity ‘red flag’ staffing incidents in line with ‘NICE guideline: Safe midwifery staffing for maternity settings’. A midwifery ‘red flag’ event is a warning sign that there may be a concern with midwifery staffing levels. The service did not provide the most recent maternity red flag data. Data between September 2024 and March 2025, which was available to us, showed the service recorded 79 red flag events. The most common red flag events were delays in the initial midwife check in triage, delayed or cancelled time critical activity, and delays between admission for induction and the start of the process. In response, the service introduced the flow coordinators and increased midwifery and medical staffing across the unit. Due to the lack of more recent data, it was not possible to identify if these changes had led to reduction in the number of red flag events.

The education team provided and monitored mandatory training for midwifery and medical staff. Maternity specific and statutory training was comprehensive and met the needs of women and staff. The training included maternity emergencies and multi-professional training, the Mental Capacity Act, infant feeding, basic life support and newborn life support. Overall compliance was 96% for all staff groups, which exceeded the trust target of 90%.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service performed well for cleanliness. The service consistently met the cleaning audit target in all areas between May and July 2025. Daily cleaning was completed by domestic staff and maternity support workers. Domestic staff had a cleaning schedule they followed and kept up-to-date cleaning records to demonstrate all areas were cleaned regularly. The service met control of substances hazardous to health (COSHH) standards.

Staff cleaned equipment after patient contact and labelled equipment with green ‘I am clean’ stickers to show when it was last cleaned. However, we observed a dirty drawer and mould in the shower in the bereavement room. This was not an improvement from the last assessment but appeared to be isolated cases.

Staff had clear roles and responsibilities around infection prevention and control. We observed staff following infection control principles, including the use of personal protective equipment (PPE) and hand hygiene. Hand washing stations and alcohol rub was available throughout the service. Hand hygiene audit data from May to July 2025 showed 88% compliance with hands hygiene standard in May, 92% in June and 90% in July 2025.

The service completed an infection prevention and control audit in all inpatient areas. This audit focused on the prevention of infections associated with peripheral vascular access devices, central venous access devices, catheter-associated urinary tract infections, compliance with MRSA screening in high-risk births and procedures, and monitoring the use of bowel charts for the management of potential infectious diarrhoea. Audit data showed 92% compliance in May, 97% in June and 88% in July 2025. The trust target was not provided.

The service did not always make sure that medicine prescription charts were managed appropriately.

Staff did not always manage medicines records accurately or keep them up to date. The service used a paper-based prescribing system. During the assessment we observed staff using a single prescription chart for multiple inpatient admissions. As a result, outdated or no-longer-appropriate medications remained listed on the chart without being crossed out, increasing the potential for medication errors. This was also highlighted at the last assessment and was escalated to senior leadership. The service reported this had been highlighted on the risk register and there were plans to introduce an electronic prescribing and medicines administration (EPMA) system by June 2026. In the interim, the service reported they would continue to remind all staff that any old prescription chart must be crossed through and removed at the point of patient discharge.

At the time of assessment, medicines management training figures were 96% for nursing and midwifery staff and 98% for medical staff.

Medication was stored securely. Fridge and freezer temperatures where medicines were stored, were monitored and staff we spoke with understood what concerns should be escalated. The ambient room temperature was also monitored.

Controlled drugs (medicines requiring additional security measures due to their potential for misuse and diversion) were stored securely and checked daily to ensure their balances were correct.