Birmingham Heartlands Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our inspection published in 2019, we rated this key question as good. At this assessment the rating dropped to requires improvement. This meant people's outcomes required improvement. The service did not always plan women's care in line with legislation and current evidence-based standards. Risk assessments were not always completed in line with guidance and staff did not understand all the risks. Staff did not always ensure outcomes were positive, consistent, or aligned with both clinical standards and the expectations of those using the service. As a result, women did not always experience care that met legislative requirements, national standards, or evidence-based guidance.

We have not awarded this service a score for Effective.

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

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

The service did not consistently plan or deliver some women’s care in accordance with legislation and current evidence-based standards. While National Institute for Health and Care Excellence (NICE) guidelines were used to support evidence-based care, the team found that only 14 out of 32 guidelines were fully compliant at the time of assessment. Eight guidelines had overdue actions or actions that had not yet been implemented.

People did not always receive care, treatment and support that was evidence-based and in line with good practice standards. For example, the perinatal mortality review tool (PMRT) highlighted instances where staff did not follow national and local guidance.

Risk assessments were not always completed in line with guidance, although the tools used were recognised and based on national standards. Supporting documentation and policies were aligned with national guidance.

Histological examination of placentas, a national requirement, remained on the service’s risk register. Despite its importance in supporting future pregnancies, there was a lack of action to improve this service, posing a potential risk in the absence of histology results and reports.

Staff provided clear information to women about their care and treatment, and several clinics and specialist midwives were available to support both physical and mental health needs.

There were effective systems to keep staff informed about legislation, evidence-based practice, and standards, including regular updates through handovers and newsletters. The service’s intranet hosted a comprehensive set of up-to-date policies covering all aspects of maternity care.

Nutrition and hydration needs were met in line with current guidance. Women had access to drinks throughout their stay, and hot meals were available at lunch and dinner. A recent audit aimed to reduce food waste and better understand women's needs, with plans to expand cultural dietary options.

The service worked well across teams and services to support people. There were lots of support services for women.

Managers ensured all staff in charge of their shift knew escalations and pressures in all areas of the maternity unit. Daily `team of the shift' meetings were held at 8.30am to discuss escalations, specific needs, and patient concerns.

Most staff told us there were good working relationships between doctors, consultants, midwives, and midwife support workers who worked closely together to provide care to women. Midwives told us their colleagues were like family, and they supported each other well on shift. Another told us "It feels like a sisterhood on here, everyone is welcomed." While most staff described a supportive environment, one staff member noted a perceived hierarchy that sometimes hindered communication between consultants and midwives.

Staff had access to the necessary information to assess, plan, and deliver care, with information shared across teams to ensure continuity. Handovers were observed to be informative and included safeguarding and other key updates.

The transitional care unit was managed by the neonatal unit. Work was being undertaken to improve working together such as including its staff in the safety huddle.

Plans for transition, referral, and discharge considered people's individual needs, circumstances, ongoing care arrangements and expected outcomes. Individualised care plans were made for women where required. For example, we saw a specialised care plan and appropriate referrals to specialists for a woman who had undergone female genital mutilation as a child.

When women moved between services, multidisciplinary teams worked together to maintain continuity of care. One example included a coordinated approach for a woman sectioned under the Mental Health Act, who was referred to a mother and baby unit. The service also collaborated with other Local Maternity and Neonatal Services through daily safety huddles to address staffing and risk concerns, and to redeploy resources as needed.

Transitional care was available on the postnatal ward for babies requiring additional support, helping to minimise separation from their mothers. Neonatal staff worked alongside midwives to provide joint care, which received positive feedback.

The care of all babies born before 34 weeks was reviewed, incorporating perinatal excellence to reduce injury in premature birth interventions to enhance service quality. A multidisciplinary audit approach was used, involving neonatal doctors and the neonatology team. In 69% of reviewed cases, there had been documented discussions about care plans prior to birth. However, the team acknowledged neonatal staff were sometimes unavailable to attend discussions due to workload, and efforts were being made to improve this.

There were good relationships between the staff and the student midwives. We spoke with a student midwife who really enjoyed working in the unit, found the staff supportive, felt part of the team and the learning was good.

However, the service did not always share information between teams to ensure continuity of care. The use of risk assessment handover tools, such as `situation, background, assessment, recommendation' was not consistent. Records were not always updated to show a risk-assessed handover had taken place. The service planned documentation workshops for staff commencing in May 2025 which included training on the use of the SBAR framework.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service did not consistently monitor women's care and treatment to drive continuous improvement. Staff did not always ensure outcomes were positive, consistent, or aligned with both clinical standards and the expectations of those using the service. As a result, women did not always experience care that met legislative requirements, national standards, or evidence-based guidance. This included failures to complete risk assessments for growth restriction, reduced fetal movements, and postpartum haemorrhage.

Risks were not consistently assessed or understood by staff. The Saving Babies Lives Care Bundle highlights the importance of identifying small for gestational age babies, yet staff did not always complete the necessary risk assessment tools for fetal growth restriction. Key indicators, such as fetal growth, ethnicity, deprivation centiles, and other risk factors were not always considered, despite their significance in predicting stillbirth and poor outcomes.

Although the service had acknowledged these issues and planned to audit all babies born under the 10th centile who were not identified during pregnancy over the next 6 months, it had not previously conducted such audits to learn from missed opportunities.

Reviews using the PMRT revealed vitamin D was not always recommended or prescribed when clinically indicated, and blood tests were not consistently repeated.

Efforts to reduce smoking rates at delivery, reported at 36 weeks, were ongoing to improve outcomes.

The stillbirth and neonatal death rate were higher than national average. The stillbirth rate reported to MBRRACE-UK for 2023 was 3.56 per 1,000 total births, which was average for similar services but more than 5% higher than the average. Between October 2024 and March 2025, the stillbirth rate rose to 4.83 per 1,000 births. Office for National Statistics (2021—2023) data showed a stillbirth rate of 4 per 1,000 births, while the West Midlands had a higher rate of 5.9 per 1,000 due to health inequalities. The neonatal death rate for the same period was 2.53 per 1,000 births, compared to the national rate of 1.26. The service's combined perinatal loss rate was 7.35 per 1,000 births, exceeding the national rate of 5.67. A deep dive into stillbirths was being conducted by the Perinatal Mortality Team to identify areas for improvement, as rates had worsened over the past 3 years.

Women did not always receive consultant reviews or timely admission and commencement of the premature birth pathway. There was a Perinatal Excellence to Reduce Injury in Premature Birth (PERIPrem) pathway to improve outcomes for premature babies, with several components relevant to the delivery suite. Although the PERIPrem midwife had undertaken education and audit work to promote the pathway, PMRT reviews showed it was not consistently applied.

We asked the trust for further information regarding the PERIPrem pathway and their compliance with implementation. Managers told us they were on track with implementation and, in some areas, performing above the regional average. The pathway was audited monthly, with findings and recommendations shared across the specialty to support continuous improvement. This included ongoing education and training for both obstetric and neonatal teams. All PERIPrem data was shared and discussed at Local Maternity and Neonatal Service meetings to ensure transparency, shared learning, and alignment across the region.

Further PMRT reviews indicated babies identified as having fetal growth restriction on scans were not always recognised or placed on the appropriate surveillance pathway. Risk assessments and medical reviews were often lacking in information or not completed. Additionally, women who developed complications during pregnancy were not always reassessed or allocated the correct risk status during labour.

There was a concern to be further investigated for women not arriving at the hospital in time to give birth. In April 2025, 1.3% of babies were born before arrival at the hospital, higher than the UK average of 0.5%. An audit found no consistent themes or required actions, but the service planned to continue monitoring this trend.

The service used the PMRT to support the review of baby deaths. We reviewed the PMRT for antenatal clinic and antenatal partum concerns. We saw actions were created to improve care for women. These included sharing guidance in the governance newsletter and review current guidelines regarding antepartum haemorrhage to ensure it is in line with national recommendations.

The service implemented a comprehensive programme of repeated audits to monitor improvements over time. Managers used the findings from these audits to enhance care and treatment. In December 2024, a `Saving Babies' Lives' dashboard was launched, enabling detailed analysis of each element within the care bundle.

Despite these efforts, outcomes for women were worse than expected. The service did not report postpartum haemorrhage (PPH) rates comprehensively, focusing only on major obstetric haemorrhage. At the PPH quality improvement working group meeting on 25 April 2025, it was agreed all PPH cases should be reviewed and monitored going forward, not just major cases.

The service did not provide the hospital-specific major obstetric haemorrhage rate. Instead, a service-level PPH rate of 3.1% was reported for March 2025, exceeding the national target of 2.7%. The service had implemented a working group to improve outcomes for women, including the introduction of pre-emptive medications for elective instrumental births and promoting optimal birthing positions to help reduce PPH rates. A PPH audit was scheduled to begin at the end of May 2025.

Women were at risk of harm from PPH and major obstetric haemorrhage due to poor risk assessment, delays in recognition and failure to activate appropriate protocols. Although there were systems for staff to follow to monitor care, treatment, and outcomes, these were not always effective. While the service reviewed women's outcomes, it did not consistently act on the data. For instance, the maternity quality and safety report from February 2025 identified risk assessments and PPH management as key themes from the perinatal mortality review tool but no further action had been taken. On assessment, we also found PPH risk assessments were poorly completed.

The service used several dashboards to analyse data and monitor outcomes in line with national standards. These dashboards were sophisticated and allowed for patient-level analysis, including outcomes by ethnicity.

Staff regularly assessed and monitored women for pain. Pain relief options were discussed during the antenatal period and upon arrival at the delivery suite. `Pain relief in labour' leaflets were available in each delivery room from a QR code. One observation included a midwife supporting an Arabic-speaking woman using a video interpreter device to explain pain relief options and ensure understanding. Anaesthetists conducted daily postpartum ward rounds to review pain management, and a midwifery handover on 29 April 2025 included detailed discussions about pain management.

The infant feeding team provided specialist support for women with complex feeding needs. They worked to reduce term admissions to the neonatal unit by reviewing incidents and identifying trends. They were progressing towards United Nations Children's Fund (UNICEF) baby friendly initiative accreditation and had reached stage 3, which involved external assessment. Following several incidents related to feeding, the team delivered training to junior doctors to improve access to infant feeding support. Nursery nurses assisted with feeding, although they reported not always having sufficient time to do so.

The service worked with the national maternity improvement advisors in the Maternity and Neonatal Safety Improvement Programme for fetal monitoring. There was a quality improvement working group. We reviewed the plan and saw they were on track with the majority of the actions.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff gained consent from women for their care and treatment in line with legislation and guidance. There were effective systems and practices which ensured women understood the care and treatment being offered, enabling them to make informed decisions. Medical staff at the service had received additional training on consent from the General Medical Council.

Women who underwent surgery signed consent forms, which documented staff had discussed the risks and benefits of treatment before any procedures. A checklist within the surgical pathway ensured consent forms were reviewed before surgery proceeded, and this was completed in all records reviewed. However, 1 consent form was found to be fully completed but crossed out, with a note stating "used 27.04.2025," despite both pages being marked through.

Women were given information they could mostly understand although some women said there were some procedures they did not fully understand. All women interviewed stated they received information in a way they could understand. Staff explained when language barriers existed, they used a video interpreting service, which they found effective. Despite this, feedback shared with the assessment team indicated a recurring concern that women and their families felt there was a lack of informed consent during care. Specifically, some reported not fully understanding the induction of labour process when consenting to it.

In some aspects of care consent was poorly documented. An audit conducted in January 2025 showed consent for caesarean sections was documented in 100% of cases. However, for other procedures, such as instrumental delivery, vaginal examination, episiotomy, and perineal repair, consent documentation ranged from 16.7% to 90.9%. The audit did not include an action plan to address these failings.

Staff demonstrated an understanding of how and when to assess a patient's mental capacity to make decisions about their care. One case involved the appropriate sectioning of a patient under the Mental Health Act, with evidence of effective multidisciplinary collaboration to ensure the safety of both mother and baby.