Leeds General 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the key question rating went down and we rated the key question as inadequate. This meant people were not safe and were at risk of avoidable harm.

The service did not always have a culture of safety and learning. Safety and continuity of care was not always a priority throughout women’s care journey. Investigations and learning were not always evident following individual incidents, and we saw women experienced further delays and omissions of care, as a consequence of this.

There was an awareness of the risks to women across their care journeys. However, records indicating how risk was measured, was not always completed. The service demonstrated some improvements with the triage systems, which had been identified from the last inspection. We saw staff communicated well to ensure women needs were prioritised.

The environment was not always safe for women. Clinical waste and storage were a concern across most areas we visited.

Medicines were not always stored or administered safely in maternity theatres.

The service did not always have enough staff for the number and acuity of patients and staffing shortages impacted the quality of care and treatment provided. Prior to and during the inspection we received concerns from staff and women, in regard to low staffing numbers and we were able to corroborate this with our onsite findings.

We were therefore not assured that there was a safe level of staffing for the service and we issued a warning notice, which required the provider to take immediate action.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Safety was not always a top priority, that involves people using the service.

The Trust used an electronic incident reporting system. All incidents are graded based on the level of physical harm and level of psychological harm.

>

All staff we spoke with understood how to report incidents and we reviewed twelve incidents logged through the Trust electronic system.

>

Incidents are reviewed against Patient Safety Incident Reporting Framework (PSIRF) national guidance and the Trust Patient Safety Incident Response Plan (PSIRP) to determine the method of investigation and appropriate review tool. The service reviews all fetal and neonatal deaths using the national Perinatal Mortality Review Tool (PMRT). We reviewed several reported incidents, graded as low or moderate harm, which were reviewed at a local weekly risk meeting in accordance with process.

>

We reviewed several reported incidents, graded as low or moderate harm, some of which were reviewed using the datix process and some at a local weekly risk meeting in accordance with process. We saw learning recorded on the datix system was not always completed. In addition, action logs completed following local review, did not always include named accountability or completion dates to ensure swift action was taken to prevent further risk of harm. Learning following incidents was not consistently shared. Managers told us information regarding incidents were shared at team meetings. However, staff told us meetings were not always possible due to operational pressures. Newsletters were issued to staff, which included incident learning. However, the Trust did not have a process to ensure which staff had read and understood this information

We spoke with staff who were not able to provide examples of practice which had been changed as a result of any learning. None of the ward staff we spoke with were able to provide recent examples of learning following incidents.

Staff contacted us following our inspection to share examples of specific incidents which staff felt had either; not been investigated or had reoccurred due to a lack of shared learning.

As a result of this information, we reviewed an additional six incidents and saw inconsistent recording of clear actions to ensure improvements were made.

Three of these incidents related to historic concerns relating to a lack of senior medical support, which had impacted staff wellbeing for several months and was ongoing at the time of inspection.

Therefore, we are not assured that the service had robust processes to ensure learning from incidents was incidents was consistently shared.

The service provided minutes of the PMRT review process, however, the minutes provided did not include those who attended the meetings. This meant we could not be assured the reviews were carried out in line with best practice guidance with all the health care professions involved with the woman's care. Following inspection, the Trust provided us with attendee lists which were kept separate to the meeting minutes. The Trust also informed us that the attendees are now incorporated into the minutes as per best practice.

>

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

As a tertiary and specialist teaching hospital, the service also accepted women and babies from outside of the region and had pathways in place to support this. The Trust used an electronic storage system for all clinical guidelines. We saw staff access documents and pathway guidelines using this system.

The service reviewed the needs of all women through twice daily staffing and ‘beds’ meetings. Staff told us women and babies at greatest risk would be prioritised and those requiring a lower level of care could be potentially moved or transferred across to St James University Hospital or post-natal ward. Decisions to move women and babies were discussed fully and shared with the accepting hospital.

We saw women presenting with specific health issues and processes in place to support pathways appropriate to these specific conditions. Staff told us these were completed to ensure women received safe care and treatment in accordance with national guidance. Triage pathway documents we reviewed were detailed and easily available in the MAC for staff.

Senior staff informed us that daily safety huddles incorporated discussions about the potential risks to women. Twice daily bed management and flow meetings were also carried out to address ongoing service pressures.

The service had also made improvements to the telephone triage assessment process, including the monitoring of repeated and drop calls. This improvement was made following feedback from the previous inspection. However, the senior midwife managing triage was also involved in some clinical ward-based activity, which at times created additional operational pressure. Overall, however this system had improved the compliance of triaging women to within 15 mins.

A labour ward coordinator had oversight of this part of the service, to ensure a helicopter view of care and performance. During our inspection we noted that the service was busy and the co-ordinator was contacted significantly, to be made aware of operational pressures. This may have become a concern because at times of being contacted, the labour ward coordinator may have lost sight of the overarching performance and delivery on the ward.

We found evidence that this circumstance was more prevalent during a night, for example to deal with issues about short staffing escalation. During our inspection we brought this issue to the attention of senior leaders of the service, who immediately initiated mitigating actions.

Staff used cardiotocography (CTG) as a method of assessing fetal well-being. In addition, central monitoring is used enabling senior midwifery and obstetric staff to continually assess and monitor the wellbeing of women and identify risks of deterioration.

We reviewed the latest maternity survey 2024 results and saw generally positive feedback in relation to receiving information and advice on risks such as those of induced labour.

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.

There was an up-to-date children's safeguarding policy in place. This provided guidance for recording safeguarding alerts for pregnant women. Safeguarding alerts were recorded on the Trusts electronic record system.

However, maternity, and neonatal services used a second electronic recording system that required an upload of safeguarding flags and alerts. There was a risk that information could be missed if both systems were not updated but we saw no evidence of this, and inspectors noted the completeness of records. Service safeguarding training compliance rates did not always meet the Trust’s internal target of 80%. The antenatal wards training score for safeguarding adults level 1 and 2 was 100% and safeguarding children level 1 and 2 was 94%.

Postnatal ward staff safeguarding adults’ level 1 and 2 was 97% and safeguarding children level 1 and 2 was 97%.

Community midwifery, fetal assessment, post-natal, medical and midwifery management staff also met the Trusts own internal target. However, one ward achieved slightly below the Trust target for safeguarding adults' level 1 and 2 at 78% and safeguarding children level 1 and 2 also at 78%.

Screening and fetal medicine staff did not meet the Trust’s target. Safeguarding adults level 1 and 2 was 63% and safeguarding children level 1 and 2 was also at 63%.

There was a trust wide safeguarding team in place for support and advice. There was a named safeguard lead nurse based on the unit and named consultant lead. There was regular liaison between the maternity and neonate teams.

Midwives referred to specialist teams if safeguarding concerns were identified. There was a specialist team to support teenage pregnancies. The ‘Haamla’ team supported women, and their families from ethnic minority groups. Women were given options to be seen at home, in the community or in hospital.

Safeguarding specialist midwives attended multi-disciplinary meetings with lead agencies to discuss current safeguarding concerns and policy updates.

Staff told us they would follow a baby abduction policy and in November 2023, the Trust had introduced a new system to reduce this risk.

During our inspection we asked the service to provide us with copies of completed abduction drills in the last 12 months, however we found that none had been undertaken. The service had a policy/procedure in place for the safeguarding of a missing or abducted child. The policy was dated April 2024 and had a review date in place of April 2026.

Access and exit points were monitored by security phone cameras and we observed a number of staff undertaking security checks with visitors attending wards or units.

The service did not always work well with people to understand and manage risks.

The service had developed dashboards to show service key performance indicator compliance. We reviewed evidence which showed performance if teams in the decision and incision timeframes for Caesarean section. We saw between March and September 2024,category 1 Caesarean, (decision to incision should be 30mins) was achieved between 85% and 76% of cases; for category 2 Caesarean, (decision to incision should be 75mins) was achieved between 87% and 77% of cases; for category 3 Caesarean (decision to incision should be 90mins) was achieved between 31% and 12% of cases.

We saw documentation audits which showed mixed results for antenatal documented evidence demonstrated. We reviewed the September 2024 dashboard and observed KPI indicators which included data on still births, post-partum haemorrhage, and tear rates. Actions to be taken were shown against each area requiring improvement. However, there was no recorded accountability against each action and no timescales in which to undertake them.

We also reviewed Newborn early warning track and trace audit dated January 2025 and saw that neonatal observations were carried out, however compliance with frequency and duration was suboptimal.

We received mixed feedback from women using the service during our inspection. Although, feedback was generally positive with women stating they felt involved in decision making and advice. We also reviewed the national maternity services survey which corroborated this.

The service did not always detect and control potential risks in the care environment. Clinical waste areas were not always stored securely. Utility rooms, which were visibly dirty, were freely accessible to inspectors and the public, creating a risk of biohazard transfer and access to chemicals. Service leaders told us that lockable cupboards were to be ordered. We saw clinical waste bags at the entrance of the post-natal unit and the bedpan macerator was out or order. Large clinical waste bins were unlocked on several of the corridors we visited.

Confidentiality at the antenatal clinic entrance was compromised, as women and their supporting families were seated immediately at the door along a narrow corridor. However, staff told us there were additional vacant rooms that could be utilised, when discussing sensitive information.

We found oxygen cylinders were not always secured and were stored underneath patient trolleys. We also saw cylinders which were unsecured across several wards we visited. We brought this to the attention of service leaders, who took immediate steps to address this.

The midwifery led unit was dark with trolleys and equipment stored at the sides of the corridors. Inspectors brought this to the immediate attention of staff who ensured lighting was immediately improved for the women on the unit.

The service had two maternity theatres located on the delivery suite and three enhanced maternal care beds for women requiring a higher level of monitoring after delivery.

The maternity unit access was fully secure. There was a monitored buzzer entry system to the labour unit, antenatal ward, maternity triage assessment unit and the post-natal ward.

The service did not always make sure there were enough qualified, skilled and experienced people, to effectively provide safe care that meets people's individual needs.

Midwifery staffing

During and following the assessment we received a number of anonymous concerns from staff regarding staffing shortages. Staff told us shortfalls impacted on staff having the time to always provide safe care and treatment consistently.

>

We instigated staff focus groups following the assessment. Staff told us they felt overlooked and that senior leaders did not always listen to their concerns regarding staffing shortages and the impact this had on moral and wellbeing. Staff informed us they did not always have time to take breaks due to clinical numbers, acuity and lack of staff to support this. Staff also informed us that band 7 midwifery staff who were rostered as clinical coordinators did always have time to undertake nonclinical duties. Due to staffing shortages, they were often required to work clinically. This impacted senior staff not always having availability to complete nonclinical tasks for example staff rostering, clinical audit or oversight of risk management.

Women provided feedback which corroborated that a shortage of staff impacted on their pregnancy pathway, including antenatal, delivery and post-natal care. They informed us staff shortages impacted on timeliness of pain relief, answering call bells in a timely way, waits for catheters to be removed post C-Section and lack of support with breastfeeding.

We saw planned and actual staffing numbers were displayed on every ward. There was a safe staffing and escalation protocol to follow should staffing levels per shift fall below the agreed roster. The service used `safecare' professional judgement tools as an additional function of the roster system to determine real time assessment of patient acuity and therefore the staffing required. A rag rating was given in accordance with the department needs and discussed in the daily staffing meeting. We observed this staffing meeting and saw no additional information was considered such as dashboard data, when deciding clinical priorities.

The Trust also used `stop the line' principles to determine the minimum safe numbers of midwifery staff for each ward or department. We observed that two sets of figures were being used and it is unclear why, however staff we spoke with reported that old figures had been set based on an out-of-date Birthrate Plus calculation rather than figures from the most recent 2024 Birthrate Plus review. This could have caused confusion for staff when escalating planned versus actual staffing. Following inspection, the Trust provided a response setting out how safe and effective staffing was maintained with a description of mitigating actions.

When staffing levels met or fell below the minimum stop the line numbers, an electronic red report was submitted by ward staff to indicate this.

A midwifery red-flag event is a sign that something may be wrong with midwifery staffing. Between May and September 2024, the service provided evidence which showed they had reported 170 maternity red flag incidents. We saw that 52% (n89) were delayed time critical activities and 41% (n70) were delays between admission for induction of labour and the beginning of the process of more than 2 hours. However, the data does show that during the same timeframe the service reported that all women had 1:1 care in established labour, and the labour ward coordinator was able to maintain supernumerary states at all times.

At the time of our inspection, there were 9 whole time equivalent (WTE) midwife vacancies in the community midwife team and 4 WTE midwifery support worker (MSW) vacancies. In addition, there were vacancies at band 5 and band 6 across maternity services in the Trust. Midwives rotated every 6 months between departments and sites to ensure they maintained their clinical skills. This resulted in vacancies being distributed across the service. The Trust were actively recruiting midwives and midwifery support workers however, at the time of our inspection had difficulty in meeting Birthrate plus staffing levels. There was not always sufficient suitably qualified and experienced midwifery and support staff deployed to keep patients safe. This corroborated the concerns raised to us by whistleblowers and we served a warning notice to the provider to ensure swift action was taken to address this.

We reviewed mandatory training figures during our inspection and found compliance to be generally high. Trust targets had been met with the exception of a small number of areas. This included PREVENT training within one team and also, fire safety and patient safety within other teams. Prevent training aims to support people susceptible to radicalisation.

Senior midwifery staff told us this that areas of lower compliance could relate to ability to access certain courses. The Trust told us mandatory and priority training is available to book and/or access online

Medical staffing

We received a number of anonymous concerns from medical and midwifery staff regarding registrar/senior house officer (SHO) rota gaps. Staff were concerned this posed a risk to mothers and birthing people due to the potential of leaving minimal cover and ongoing medical oversight at times of high acuity and demand.

>

The Trust had developed a process to ensure where rota gaps were identified there could be mitigated. The escalation process for additional staff included requests for surge rates to attract cover.

>

We noted some gaps in rotas were highlighted on day and night rotas. We escalated this with senior leaders at the time of the inspection and we received assurance that the service had a process in place to manage medical staff rotas. Most staff told us that medical cover was sufficient, however the antenatal unit had no dedicated medical cover. Staff told us this resulted in delays for women waiting for medical review and assessment and certain prescriptions such as iron. One staff member described regular delays with mothers experiencing reduced fetal movement. All staff on the antenatal unit, spoke of frustrations with delays waiting for doctors to attend to waiting women.

We reviewed Birmingham Systems Specific Obstetric Triage System (BSOTs) audit data submitted by the service dated December 2024, but we were not assured that reviews carried out by doctors were audited, as they were not included.

Nursing staff told us a new system had been introduced in which concerns could be escalated to team leaders. Team leaders were supported by in onsite matron and decisions could be made to move women to appropriate wards when required. This system had only recently been introduced.

There was not 24-hour consultant cover at this location. Consultants were on call overnight and expected to be able to reach the hospital within 30 minutes of being called. However, we saw incident reports which showed delays in consultants attending when called. This issue was ongoing at the time of inspection.

Medical staffing was monitored by the clinical director through a monthly medical staff assurance meeting attended by human resources, lead clinicians, college tutors and a business manager for the service. This meeting reviewed sickness escalations, where absence triggers are met and ensured processes were in place for those with long term sickness. However, Resident doctors told us there was no protected time for learning or induction when they were new in post. This posed a risk to women, as medical staff may not have completed the required learning prior to undertaking triage.

We requested formal mandatory training rates from the provider and saw mandatory training completion compliance figures were below the Trust's own target of 80%.

>

For example, adult resuscitation compliance was 73%, equality, diversity and human rights compliance was 67%, patient safety compliance was 60%, safer blood transfusion compliance was 62%, venous thromboembolism compliance was 67% and PREVENT training compliance was 62%.

>"}

The service did not always assess and manage the risk of infection. It did not detect or control the risk of it spreading or share any concerns with appropriate agencies promptly.

The lead IPC nurse had recently left her post to become a matron elsewhere within the organisation. Staff told us that the once fortnightly held IPC meetings had become difficult to arrange due to this and the additional staffing pressures and we saw meetings were inconsistent. Although The CSU had support from the Trust IPC Team and had a dedicated Clinician and Matron who led on IPC and provide support to the clinical teams. All ward/unit areas displayed a clean star rating showing monthly compliance scores. All wards we visited showed high compliance rates; however, we saw wards which were visibly dirty. For example, the post-natal ward which scored 100% compliance at the last audit in December 2024 was found to be visibly dirty in certain areas. We also observed a household bin marked ‘offensive waste’ which was stored in an open sluice room.

We found staff personal food items within the sluice room on one ward, which was also found to be unlocked.

We reviewed audit scores for visual infusion phlebitis following device insertion and we noted poor compliance across several wards in the last three months. For example, in the December 2024 audit, a post-natal ward achieved 65% compliance and in October 2024 the delivery suite achieved 50%. The audit narrative suggested that this was due to incomplete data submissions, however the service did not resubmit any new or additional data.

Most nursing staff we reviewed had completed mandatory infection prevention and control training. However, medical staff at the fell below the Trust own mandatory training compliance target for IPC at 67%.

We requested hand hygiene audits from the service and saw that they were at 100% compliance.

The service did not always make sure that medicines were stored, administered and managed safely, in accordance with prescriber instructions and best practice guidelines to make sure that people who used the service were not placed at risk.

Within theatres we found ondansetron and sodium chloride pre drawn syringes with no strength identified on the label. Staff told us this is routine practice to draw these up, including basic emergency drugs co-amoxiclav, dexamethasone and ondansetron, every morning. This is a risk to women, as the incorrect medicine may be given. . We brought this to the attention of the Chief Pharmacist who told us anaesthetists were expected to follow the Royal College of Anaesthetists guidelines for drawing up and labelling medicines, as set out in the Trust Medicines Code and Injectable Medicines Code.

Service leaders took immediate steps to ensure anaesthetic staff were reminded to follow this guidance correctly.

We also found intravenous fluid bags were not locked away on the delivery ward in line with guidance. This posed a risk to women, as fluids may have been tampered with or removed.

The Trust had a Medicines Code (accessible electronically) that was divided into chapters for ease of navigation for staff to follow. The standards for safe and secure handling and use of medicines were described in the Code. There was a chapter specifically for Non-Medical Midwife Prescribers. The Trust use an electronic signoff for Patient Group Directions (PGDs) that had been agreed through the Prescription Stationery Group which is a subgroup of Medicines Safety Group.

Staff told us there were very few nurse prescribers, which exacerbated some delay for women waiting in the day and ante natal unit.