Birmingham Heartlands Hospital

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• 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

The service was not proactive in recognising and learning from safety incidents. There were delays in triage and in induction of labour. Staff did not always follow national guidance on scanning and antenatal care and there were inconsistencies in cardiotocography (CTG) categorisation and failure to escalate concerns in a timely way. Women were not consistently informed about risks or how to keep themselves safe. The service did not always identify or manage potential risks within the care environment. Staff did not ensure equipment, facilities, and technology adequately supported the delivery of safe care. Staff did not ensure medicines were stored securely. The service did not ensure women were safe and protected from avoidable harm.

At our last assessment, we rated this key question inadequate. At this assessment, the rating has remained inadequate.

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 was not sufficiently proactive in recognising and learning from safety incidents and there was evidence some women were coming to harm. Lessons were not always learned which meant staff did not always continually identify failings and ensure improvements were achieved. Staff did not always hear concerns about safety and did not always learn lessons from previous outcomes. For instance, the service did not report postpartum haemorrhage (PPH) incidents involving blood loss under 1,500 millilitres. This was against national reporting guidance which required all PPHs over 500 millilitres to be reported. Following the assessment, the service included monitoring blood loss between 500 millilitres and 1499 millilitres as part of their dashboard.

However, staff reported there was an emerging positive shift in safety culture, driven by new leadership and structural changes. This included a sense of growing transparency and the need to focus on learning from incidents. Managers introduced `round tables' investigations and discussions following serious incidents to involve all staff. These were said to be supportive and conducive to open discussion.

When they were identified, there was a process for incidents to be reviewed promptly. There was a rapid review meeting, occurring 3 times a week, with senior oversight intended to ensure prompt identification and action on immediate learning. Learning from incidents was shared through weekly briefs and a quarterly governance newsletter. The service also circulated a bi-weekly `Weekly Brief' newsletter to share learning from incidents.

Women and staff were encouraged and supported to raise concerns and felt confident they would be treated with compassion and without negative repercussions. The service reported 100% compliance in investigating maternity complaints, with 95% completed within the 65-working-day agreed timeframe. Since December 2024, 32 complaints were received. The most common themes were clinical treatment, mismanagement during labour, delays in care and communication. However, partner agencies reported concerns as to some complaint responses were perceived as generic and lacking detail.

Managers told us lessons were learned from incidents and complaints, but evidence showed this was not always the case. Perinatal mortality review tool findings indicated the service did not consistently learn from events. This included delays in antenatal care, inadequate risk assessments, delays in induction of labour during sensitive situations such as baby loss and missed cases of small for gestational age babies. However, we did see some examples of learning from incidents. For example, it had been identified from incidents how consultants were not regularly reviewing postnatal readmissions, leading to unnecessarily prolonged stays. In response, a day-3 postpartum consultant review was introduced which had reduced the length of stays.

The clinical governance and education workstream were concentrating on reducing the patient safety backlog in their incident reporting system, embedding the maternity quality and safety framework, and addressing outstanding actions from incidents.

The clinical pathways redesign and quality improvement workstream continued to support staff training in quality improvement methodology and focused on areas such as enhanced maternal care, induction of labour, reopening of midwifery-led units, antenatal care, diabetes care in pregnancy, and embedding quality improvement practices within maternity services.

Information about women was not always communicated effectively between health professionals. The service did not consistently use the SBAR (Situation, Background, Assessment, Recommendation) framework, a key risk management tool for communicating information about people between health professionals. We reviewed 7 sets of notes and found this was not consistently completed. The delivery suite manager acknowledged the issue, noting it had been identified during internal reviews and staff had been reminded of its importance. An audit conducted by the Health Services Safety Investigations Body in April 2025 found 40% compliance with information being completed for digital handover processes, with just 38 out of 94 handovers completed with all information required. The service planned documentation workshops for staff commencing in May 2025 which included training on the use of the SBAR framework.

Women were mostly reviewed by midwives in triage with the recommended timeframe based on their level of risk. Midwives were expected to provide triage coverage 24 hours a day, 7 days a week, with a target compliance rate of 85% of women to be seen within the time required in terms of their risk categorisation. In records we reviewed covering 10 January and 1 May 2025, the service demonstrated monthly compliance rates for being seen within the timeframe ranging from 74.8% to 99%. The overall average compliance was 91%, indicating that the service mostly met and sometimes exceeded the expected standard. The lowest recorded compliance was 40%, and there were 24 instances where compliance fell below the 85% target.

However, women were not always reviewed promptly by the doctors upon arrival to triage in accordance with the Birmingham Symptom Specific Observation Triage System (BSOTS) which was the trust's preferred guidance.

The service aimed to provide triage cover 24 hours a day, 7 days a week, with a target compliance of 85%. The data reviewed between 10 January and 1 May 2025 showed 71% of women were seen by a doctor within the recommended timeframe. This was below the expected standard. There were 26 days where the service met or exceeded the 85% target, reflecting strong performance in some areas. However, there were also 13 days where compliance fell below 50%, with the lowest recorded compliance being 31%. We were told the service was not fully covered. This was mostly at night. Two resident doctors were allocated to triage from 8am to 8pm Monday to Friday. On a Saturday and Sunday, triage cover was provided by 1 doctor from 8am to 9pm, and a second from midday until 8pm on Saturday and Sundays. This allocation exceeded the Royal College of Gynaecologist recommendations for medical staffing in triage but women were still experiencing delays as this was not always being achieved.

Triage delays were discussed in governance meetings, and while no harm was reported, documentation often failed to reflect the actual time of women's reviews. Doctors did not always document the time they reviewed the woman and this presented as a delay. Leaders had educated the medical staff and added it into the induction program for all new doctors

Additionally, women admitted or readmitted antenatally were not always seen by a consultant within the nationally recommended 14-hour timeframe. Consultant reviews typically occurred the following day during ward rounds.

There were delays in induction of labour due to limited bed availability. During the assessment and in reviews of patient safety events from October 2024 to April 2025, several cases were identified where women waited 4 to 6 hours for treatment due to lack of operating theatre space. One such delay resulted in a major obstetric haemorrhage. However, there was a process which was followed to ensure prioritisation of the highest risk women first.

We asked maternity service managers to provide assurances around addressing delays for women awaiting induction of labour (IOL), artificial rupture of membranes (ARM), and theatre procedures. They provided an action plan which included the following:

• To review of the IOL guideline to ensure inclusion of the management of delayed IOL.
• To undertake prospective audits into IOL and ARM delays.
• The IOL and ARM oversight tool to be used daily and presented at the daily huddle for oversight.
• The IOL quality improvement group to implement and monitor agreed key performance indicators for their priorities including reducing delays, reviewing decision making, indication for induction, booking process and experience, and cervical sweep clinic.

The service did not always follow national guidance on scanning and antenatal care, which posed potential risks to women and babies. Some women with abnormal scan results were contacted by phone, while others were required to attend hospital for daily fetal monitoring but this did not follow national guidance. Perinatal mortality review tool case reviews highlighted recurring issues with antenatal clinic appointments and scans, missed referrals to fetal medicine, missed screening opportunities, and unclear advice regarding low-lying placentas and fetal movements. These concerns persisted despite the existence of a working group and inclusion of scanning issues on the service risk register.

We asked the maternity leaders for further assurances regarding the scanning issues we found. They told us governance of ultrasound services was overseen by the trust Ultrasound Multidisciplinary Steering Group, which audited and reviewed all ultrasound related incidents. They had an ongoing action plan, with updates reported to the Maternity Specialty Meeting. To support appropriate scan utilisation, the Lead Midwife for Sonography had been tasked with conducting a 3-month prospective audit of scan referrals.

Some women were not seen in line with national guidance with excessive appointments which presented a risk to other women being unable to be seen in a timely way. Women reporting reduced fetal movements were seen daily until they felt reassured, with some attending daily for up to 6 weeks. This practice was not aligned with national guidance or evidence-based care.

Inconsistencies in cardiotocography (CTG) categorisation and failure to escalate concerns according to national and local guidance in a timely way posed a risk of harm to women and their babies. Deteriorations in fetal wellbeing from fetal heart monitoring were not always recognised by staff or acted upon promptly impacting on the outcome for the baby and woman. In 4 sets of notes reviewed, and in 2 additional Learning From Patient Safety Events between October 2024 and April 2025, there were inconsistencies in CTG categorisation. Some CTGs marked as normal were later identified by our midwifery specialist advisor as abnormal, indicating a failure to recognise and escalate concerns appropriately.

The maternity improvement team conducted a thematic review of baby loss, stillbirth, and neonatal deaths, which highlighted the service's booking pathway was too consultant focused. In some cases, it was unclear why women were allocated to consultant-led care despite having no identifiable obstetric or medical risk factors. Of the cases reviewed, 88% were booked under consultant-led care, and in 25% of these, the management plans were considered inappropriate.

There was a collaborative, joined-up approach to safety that involved women and specialists in their care. Women were referred to appropriate specialist teams to ensure they received the care required during their pathway. For example, if a woman was found with female genital mutilation, she would be referred early to a specialist midwife and monitored throughout her antenatal care, with a clear plan for labour and postnatal care.

Staff had a good understanding of safeguarding and mostly how to take appropriate action. Women were supported to understand what safeguarding meant, how it applied to them, and how to raise concerns if they felt unsafe. While overall safeguarding training compliance was good across staff groups, resident doctors had a notably low compliance rate, reported at 60%.

The service had an accessible safeguarding policy and pathway. Staff knew how to make a safeguarding referral and who to contact with concerns. There was a maternity safeguarding team who were visible and contactable for advice. The safeguarding team attended daily safety huddles at 9am and 4pm so they were sighted on any potential safeguarding cases. Community midwives referred women antenatally to the safeguarding team, who continued to support them during their hospital stay. The team also provided training and supervision as needed.

There were effective systems and practices to protect people from abuse and neglect. In 2 observed cases, women who had experienced female genital mutilation were appropriately referred to a specialist midwife, and care plans were implemented to safeguard them and their babies. The service demonstrated a commitment to taking immediate action to protect individuals, working collaboratively with partners. The safeguarding team had established a multidisciplinary group to lead focus groups for identified women, including a new continuity of care team offering targeted support for vulnerable women.

During the assessment, appropriate section paperwork was completed for a woman detained under the Mental Health Act, and there was effective collaboration with the mental health team in her care.

The service had a baby abduction policy and staff reported participating in practice drills, including 1 in October 2024. Staff were familiar with the policy, ward areas were secure, and doors were monitored. Newborns were fitted with electronic tags that prevented them from leaving the building; doors remained locked if a tagged baby approached. Tags were removed at discharge.

However, the service did not always work well with women in all circumstance to understand what being safe meant to them and the best way to achieve that. During the assessment, a woman detained under the Mental Health Act was receiving interprofessional, multidisciplinary care focused on her safety and that of her baby. However, there were no safeguarding risk assessments for the other women and babies on the same ward, and the potential risks to them had not been fully considered.

The service did not work well with women to understand and manage risks. Staff did not provide care to meet all women's needs that was safe, and supportive and enabled them to do the things that mattered to them.

Women were not consistently informed about risks or how to keep themselves safe. Communication with women during the antenatal and postnatal periods was inconsistent, particularly when action was required. During the assessment, recent incidents revealed community midwives were not always informed about the discharge of mothers and babies. In one case, a baby requiring significant treatment was discharged home due to a communication failure and was later readmitted for urgent care.

The service was not delivering care to all women with diabetes in line with national guidance, as reflected in incident reports, including some delays in induction of labour and artificial rupture of membranes. The service reported an insufficient number of diabetic specialist midwives to support this high-risk group. Women requiring specialist diabetic care did not receive adequate blood glucose monitoring, and some missed essential scans, placing them at risk of harm. These issues were on the service's risk register. The service had worked to mitigate this risk by increasing staffing, putting extra clinics on, recruiting 2 additional maternity support workers to support the specialist midwives and had a quality improvement group with regular meetings with the head of midwifery to monitor the risk.

Certain risks to women and babies were not assessed in accordance with national guidance. Staff lacked sufficient understanding of available risk assessments, including those outlined in the Saving Babies Lives Care Bundle version 3. This guidance was intended to identify women and babies at greatest risk of complications, such as fetal growth restriction and preterm birth, which had higher risks of poor outcomes. However, risk assessments were not consistently completed, and there was a chance some women were not identified as being at risk.

Not all staff were up to date with training to manage obstetric emergencies putting women and babies at risk of potential harm. Although the service held an obstetric emergency training day, compliance with the 90% training target was not met. Midwives had a compliance rate of 76%, midwife support workers 77%, and theatre staff 64%. Only doctors and anaesthetists met the required target of 90%. The service had launched a new training programme in January 2025 with a clear action plan. Because of this, they expected an initial deterioration in compliance before the position was corrected.

The `fresh eyes' approach for electronic fetal monitoring was not consistently implemented in line with national guidance from National Institute for Health and Care Excellence (NICE) (NG229). This guidance required hourly in-person reviews of cardiotocograph (CTG) assessments by another clinician — or what was known as `fresh eyes'. In February 2025, the service reported 90% compliance with labour assessment reviews, but this was based on a small sample. The same month, compliance with the fresh eyes protocol was only 50%. An audit reported an increase in patient acuity and lack of staffing as the reason for delays. In the October 2024 audit, of 26 missed fresh eyes reviews, 14 were late by between 18 and 48 minutes and 12 were not completed at all, placing women and babies at risk of harm.

During the onsite assessment, we reviewed 4 sets of notes and found the fresh eyes for electronic fetal monitoring had not been undertaken in all 4 cases. For example, in the notes we reviewed, a patient went for 5 hours without a cardiotocography (CTG) review from another clinician in contravention of guidance around safety.

Incorrect categorisation of CTGs and failure to escalate concerns according to national and local guidance in a timely way presented a risk of harm to women and their babies. A review of patient safety events from October 2024 to April 2025 found 2 additional cases with CTG categorisation errors. Evidence of potential harm was also noted, including 1 case where a woman required repeat CTG monitoring that was significantly delayed and ultimately not completed, despite her reporting reduced fetal movements.

We asked to trust how they were assured staff were sufficiently trained to interpret, document and escalate CTGs appropriately. Also, how they were conducting fresh eyes CTG review following local and national guidance including appropriate escalation when fetal wellbeing deteriorated. The managers provided actions which included the following:

• Revise the fetal monitoring training day, including a revision of the competency document.
• Strengthen intrapartum leadership and appoint 2 intrapartum midwives to support improvement on this work.
• Produce and issue a patient safety brief in relation to CTG interpretation, documentation and escalation.
• To implement a focused programme of `floor walks' by a practice development midwife, and fetal monitoring lead for the next 3 months with real time feedback provided to the staff.
• Implement documentation workshops which included fresh eyes documentation.
• Evaluate the effectiveness of the quality improvement project through audit of fresh eyes post workshop.
• The fetal surveillance quality improvement group to implement and monitor agreed key performance indicators.

There was a lack of strong evidence as to how managers were acting on risks identified through reported data. The maternity quality and safety report for January 2025 recorded 5 stillbirths, with 1 case raising concerns about fetal monitoring management and classification. The report also highlighted ongoing issues with the recognition and interpretation of abnormal fetal monitoring. A review of 4 sets of notes involving continuous CTG monitoring revealed CTGs were documented as normal, despite being abnormal. It was unclear whether staff were consistently recognising or escalating sub-optimal CTGs and the associated risks.

Women were at risk of harm from postpartum haemorrhage (PPH) and major obstetric haemorrhage (MOH) due to inadequate risk assessment and delays in recognition and response. Antenatal risk assessments were not routinely completed, and PPH risk assessments were not always carried out during labour, despite their importance in identifying the likelihood of PPH; these should be completed for every labouring woman.

In 3 set of records we reviewed, for women who experienced PPH no records had a fully completed risk assessment. One woman reported experiencing a MOH of 1,500 millilitres. She stated the MOH protocol was not followed, with no anaesthetist involvement, delayed fluid administration, no blood transfusion, and a general lack of recognition of her condition by staff. She expressed concern that not all necessary actions were taken.

Between October 2024 and April 2025, a review of patient safety events identified incidents of PPH and MOH where delays in initiating the MOH protocol placed women at risk of harm. The service reported 75 MOH cases in March 2025 and 61 in February 2025 but did not report PPH cases involving blood loss under 1,000 millilitres. As a result, the trust board and senior leaders lacked full visibility of the potential harm experienced by women and did not have the opportunity to request a focus on reducing overall PPH rates.

The maternity quality and safety report from February 2025 highlighted recurring themes from the Perinatal Mortality Review Tool, including inadequate risk assessments and poor management of post-partum haemorrhage. In response, a working group was reconvened to implement improvement actions. The trust provided us with an action plan with immediate actions to improve compliance. Actions included:

• Re-launch the postpartum management checklist on paper form until a digital solution was agreed.
• To audit compliance with PPH risk assessments which included documentation.
• PPH risk assessment process would be included in emergency scenario training.

Staff put patients at risk of harm due to lack of engagement with the operating theatre World Health Organisation (WHO) surgical safety checklists. We saw the checklists were completed, but staff engagement was not always focused. During a caesarean section on 30 April 2025, we saw staff completing the checklist without active participation from the whole team. Poor communication among the theatre team contributed to a drug error. Staff told us inattentiveness during checklist completion was not uncommon. Following our feedback, service leaders increased audit activity and spot checks and communicated expectations regarding staff behaviour during this safety process.

Women were put at risk of harm due to staff not following national guidance regarding swab counts following surgery. During another caesarean section, the sign-out section of the WHO checklist was completed at wound closure, including a swab count. However, the procedure continued, and additional swabs were used but not counted, deviating from national guidance and presenting a risk to the patient.

A review of patient notes showed the WHO maternity surgical checklist lacked signature boxes for each section, contrary to National Patient Safety Authority recommendations. Although signature boxes existed for the anaesthetist, obstetrician, and scrub nurse, the same individual printed all names without signatures, breaching General Medical Council and Nursing and Midwifery Council protocols. The checklist was being revised by the service to align with national guidance across both hospital sites.

We asked to trust to provide assurances around addressing the poor compliance to the WHO checklist. The managers provided an action plan which included the following:

• Reminder to staff regarding the importance of the WHO checklist.
• To complete daily spot check audit for a period of 3 months with real time feedback provided.
• WHO task and finish working group to be established to discuss issues and concerns in theatres.

There were inconsistent approaches to record management putting women and babies at increased risk due to lack of awareness of their full clinical picture. In all 7 of the records we reviewed, we found handovers, risk assessments, and fresh eyes reviews were not completed. There was no evidence of the required 2-hourly `review of care' for low-risk patients in labour.

Perinatal mortality review tool reports indicated women's calls to triage were sometimes unanswered. Additionally, triage staff did not consistently follow national guidance for managing raised blood pressure and suspected pre-eclampsia. The service did not offer placental growth factor-based testing for suspected preterm pre-eclampsia, despite national recommendations.

Data provided by the service had shown a high number of babies born before the woman arrived at the hospital when compared to the national average. This posed a risk to women and their babies when not being cared for in the appropriate environment. The service had audited this but found there were no themes but continued to monitor due to high rates.

Sepsis audits were not reviewing a statistically significant number of records. The service carried out a sepsis audit and looked at women who had sepsis between December 2024 to February 2025. However, the audit was not proportionate to the service's birth volume. A sepsis audit reviewed only 25 cases. Results showed just 72% of women received antibiotics within 60 minutes and all had blood cultures taken and a senior review within 1 hour. There was an associated action plan for developing the audit further including potential to increase the sample size. Sepsis management was part of the maternity improvement project on deteriorating patients and this also included a sepsis steering group.

In cases we reviewed, there were delays in administering intravenous (IV) antibiotics on 2 occasions in one day for a woman whose Maternity Early Warning Scores indicated increased risk, resulting in deterioration. In another case, a delay in IV antibiotics for a high-risk woman increased the risk of infection transmission to her baby, contrary to guidance.

However, Staff used nationally recognised tools to identify risks of deterioration in women and babies. Staff used national tools such as the Modified Early Obstetric Warning Score (MEOWS) for each woman and Newborn Early Warning Scores (NEWS) for each baby. In all sets of notes reviewed MEOWS and NEWS were consistently recorded.

The service continued to experience delays in facilitating inductions of labour (IOL), primarily due to staffing levels and patient acuity. These issues were on the service's risk register. During the onsite assessment, it was noted while delays for women already on-site were reported, delays for those awaiting IOL at home were not. Delays in elective procedures and artificial rupture of membranes (ARM - breaking of waters) were also not consistently reported, despite being recognised as red flags. The service had a process where senior midwives and consultants reviewed and prioritised care plans for women experiencing delays, including those waiting at home. The risk register, last updated in October 2024, reflected this was an ongoing concern. Data from January to March 2025 showed continued delays in ARM due to bed shortages, as reported in governance papers. A quality improvement plan and working group had been created to address IOL management.

The service did not consistently identify or manage potential risks within the care environment. Staff did not ensure equipment, facilities, and technology adequately supported the delivery of safe care. Women were not always cared for in environments that were safe or appropriately designed to meet their needs, although there was an excellent new triage facility. A lack of space in the antenatal wards resulted in antenatal patients being accommodated in the delivery suite, reducing space for women in labour. This was on the service risk register and there was an improvement project to address the capacity on the antenatal wards.

There was an issue, which was resolved, around security of an operating theatre and its suitability. When we were on site, operating theatre 2 was found to be unlocked and accessible to unauthorised people. This theatre, located in the centre of the delivery suite, contained medicines, sharps, and medical equipment. Concerns were raised with the theatre manager, who responded promptly by arranging for a keycode lock to be installed the same day. Operating theatre 2, used as a backup, was too small to safely accommodate emergencies involving both mother and baby. This issue was recorded on the service’s risk register and was scheduled to be addressed in the next phase of building work.

At our previous assessment we found triage facilities were not fit for purpose. This time we found a new purpose-built triage area had been commissioned which was specifically designed to meet the unit’s needs.

There was a good standard and range of equipment but it was not always stored securely. The service had suitable equipment, including portable ultrasound scanners, cardiotocography machines, and observation monitors, to support safe care. While the equipment was appropriate for its intended use, it was not always stored securely, and some items were found to be out of date. Although emergency trolleys were generally checked daily, the lack of secure storage posed a risk of items being removed. Out-of-date equipment was also found on the neonatal trolley. Ligature risk assessments were incomplete across several wards. Ligature cutters were not readily available in most areas, although they were present on the delivery suite but not easily accessible. This issue was identified in a safety audit, and ligature training was reported to be in progress.

The estate’s workstream priorities included developing business cases for capital funding at the maternity unit, refurbishing the delivery suite, expanding the neonatal unit to address safety concerns, upgrading theatre facilities, and addressing the inadequate layout of Aspen ward.

The service recently extended birthing partner visiting hours to 24 hours a day. However, the facilities were not suitable for overnight stays, and staff reported finding partners sleeping on the floor or in beds with their partner women. The service recognised the challenges and had approached charities to support funding for convertible armchairs/beds.

The bereavement suite, known as the Eden Suite, provided a private and sensitively designed space with 2 bedrooms, a lounge, a mortuary, and a private garden. Families could access the suite through a separate entrance and stay as long as needed, allowing them time to grieve and receive support.

The maternity unit was fully secure, with monitored entry and exit systems for each area. Security personnel were present at the front entrance 24 hours a day, 7 days a week, checking all individuals entering the building.

Clinical waste was managed safely, with correctly labelled and appropriately filled sharps bins. Staff followed proper procedures for separating and disposing of clinical waste.

The service did not consistently have sufficient staffing to meet the needs of women, primarily due to sickness and maternity leave among the midwives and high levels of care required for women. Managers adjusted staffing levels based on the number of women in clinical areas and their acuity, but the number of midwives and maternity support workers often fell short of planned levels. Acuity is the assessment of a woman's clinical needs and the corresponding level of care required. Daily shortages of midwives were reported, with the delivery suite typically staffed with 10 to 11 midwives each shift against an establishment of 12. For instance, on 30 April 2025, we saw 10 midwives were present out of the planned 12.

Midwifery staffing shortfalls impacted the quality of care. Compliance with the fresh eyes safety check was only 50% in February 2025, with acuity stated as the cause of delays. Staff were often moved between areas to manage acuity, such as on 29 April 2025, when a maternity support worker from Cedar Ward was reassigned to the delivery suite. However, staff reported some improvement in staffing and fewer reassignments.

Delays in the induction of labour were attributed to midwife staffing issues. This was on the risk register. Mitigations included a rolling recruitment programme, twice-daily staffing safety huddles, active roster management, and escalation protocols. Despite these efforts, many inductions were still postponed to the following day.

Women were put at risk of potential harm due to the lack of high-dependency trained midwives. There was not always a high dependency trained midwife available on each shift, despite efforts by managers to ensure coverage when there were high-dependency unit beds on the delivery suite. The enhanced care facility was supported by the anaesthetists, labour ward co-ordinator and the trust outreach team. On 30 April 2025, there were 5 women in high-dependency beds. To address the increased acuity, 2 additional midwives were provided to support the area. The advanced care practitioner midwife began training staff in enhanced maternal care. However, midwives caring for high-dependency patients did not consistently have the necessary qualifications, posing a risk to patient safety. There were plans to introduce enhanced maternity care training.

Not all training was up to date. For example, not all staff had updated their fetal surveillance training. The service held a fetal surveillance training day, but completion rates in March 2025 were below the 90% target: 73% for midwives, 87% for doctors, and 89% for consultants. There was practical obstetric multi-professional training and a course on the care of critically ill pregnant or postpartum women, with ward-based simulations. Training compliance data showed 76% of midwives and support workers and 71% of theatre staff had completed the training, falling short of the 90% target. In contrast, compliance among doctors and anaesthetists exceeded 90%. The service had launched a new training programme in January 2025 with a clear action plan. Because of this, they expected an initial deterioration in compliance before the position was corrected."

There was a manager assigned to a `safety and capacity' role each day. They did a walkaround of each area and arranged moves and staffing throughout the day. There was a meeting twice daily and staff were reallocated and moved based on the acuity at both Good Hope Hospital and Birmingham Heartlands Hospital.

The service did not use agency midwives. However, there had been a noticeable reliance on internal bank staff to support safe staffing levels. Between March 2024 and April 2025, bank staff usage ranged from 11.2% to 23.8%, with fill rates for vacant shifts between 50.8% and 79.5%. Enhanced pay was introduced to improve uptake, but unfilled shifts still led to inadequate staffing in some areas, causing delays for women awaiting induction.

A daily 8.30am `team of the shift' meeting brought together departmental leads to discuss staffing, discharges, risks, and medical cover. We observed a meeting on 29 April 2025, and staff highlighted shortfalls in staffing, potential discharges, risks and doctor cover in all areas.

At the time of our assessment, the midwifery vacancy rate stood at 4%, meeting the target. Some vacancies were expected to be filled by newly qualified band 5 midwives. Staff acknowledged ongoing challenges but reported improvements since the previous assessment. The delivery suite aimed for a staffing acuity target of 85%, but in March 2025, it was only 47%. A high acuity score meant the midwifery staffing was adequate for the level of acuity of the women being cared for on delivery suite at that time. Acuity had been 85% in January and 82% in February.

Community services faced significant staffing gaps, with 24 whole-time equivalent vacancies for community midwives across the system. Bank staff supported the service, and efforts were made to optimise time and increase appointments, such as introducing postnatal clinics in place of home visits. A new integrated band 5 midwife role had been introduced where they worked on delivery suite 1 day and 3 days in the community, supported by the preceptorship team. Labour ward coordinators were expected to be supernumerary, with compliance ranging from 89% to 95% between November 2024 and February 2025.

Birthrate Plus data showed 1-to-1 care during labour was below the 100% standard, ranging from 94.4% to 99.3% between March 2024 and February 2025. This was considered a red flag by the National Institute for Health and Care Excellence (NICE), indicating potentially low staffing levels.

Staff received support through supervision, appraisals, and professional development.

The service used an acuity tool to determine if there were safe staffing levels across all shifts and departments. Data was submitted 4 times every day, generating a red-amber-green rating called the operational pressure escalation levels (OPEL) status. This information was shared across the Local Maternity and Neonatal System (LMNS) and discussed in staffing meetings. The LMNS is a partnership of people involved in maternity and neonatal services, working together to improve services. A first contact matron was available daily to support and resolve issues, ensuring women awaiting induction were assessed and monitored.

There was evidence of strong collaboration within the LMNS to improve services. Senior leaders held twice-daily meetings to review acuity, staffing, and associated risks, in line with the OPEL process. Staff were redeployed as needed to maintain safe care. When internal redeployment was insufficient, the escalation policy allowed for community midwives to be brought into the hospital, which could lead to suspending the home birth service as a last resort.

Medical staffing levels were insufficient in triage to consistently provide timely care. There was no doctor dedicated to triage overnight and women were not always seen within the recommended timeframe which presented a risk to women and babies. There were 2 doctors allocated to triage between 9am and 8pm. Overnight the service relied on on-call doctors who also covered delivery suite and postnatal wards. However, with 2 doctors allocated during the day, the service exceeded the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines which only recommended 1 allocated doctor to cover "in hours" and a speciality doctor to cover a peak times. The data reviewed showed an overall average compliance of 71% of women between January and 1 May 2025 being seen at triage in the recommended timeframe. This was below the expected standard. There were 26 days where the service met or exceeded the 85% target, reflecting strong performance in some areas. However, there were also 13 days where compliance fell below 50%, with the lowest recorded compliance being 31%.

At our previous assessment, we served a Warning Notice to the trust due to inadequate medical staffing in triage. While the service had increased the number of doctors and the times they were available, delays remained for women particularly overnight.

We asked the maternity leaders for assurances that these delays were not causing harm to women and babies. They told us triage activity was monitored twice a day at the staffing huddle with the dedicated on-site matron ensuring high-risk patients were prioritised for review. There was a defined escalation pathway for staff to follow when patients were identified as being at risk. Any breaches, where patients were not reviewed within the recommended timeframe, were monitored daily and analysed for themes. This fed into a fortnightly assurance meeting. Any triage specific insights were reported at the triage working group and incidents were examined in governance meetings. Evidence we reviewed showed themes for poor compliance included staffing, capacity and resilience.

Apart from triage, the service maintained a good skill mix of medical staff per shift and regularly reviewed staffing needs. Locum doctors were used to fill staffing gaps and received full inductions. Consultants were on site from 8am to 11pm and on-call outside these hours. Consultant ward rounds took place as expected at 8am and 8pm when the on-call consultant attended the ward to carry out the ward round.

Staff reported consultants were accessible and approachable. However, the service's risk register highlighted an inadequate obstetric skill mix and gaps in the resident doctor rota, affecting both patients and staff. Leaders reported an obstetric and gynaecological workstream aimed at increasing staffing and service provision, which was 19% complete as of February 2025. Following the assessment, leaders told us they had recruited 5 consultants who would start by the end of October 2025 and the service had been approved for a further 10 consultants.

A dedicated anaesthetist was available 24 hours a day, 7 days a week for the labour ward and conducted postnatal reviews for women who had received anaesthetic care in the previous 24 hours.

Recruitment and performance processes were fair and regularly reviewed to ensure equity. The matron had completed strength-based recruitment training and delivered sessions to managers.

Cedar Ward piloted a student-led learning model with 2 bays managed by 8 students during weekday day shifts. A dedicated midwife supervised the students, who each cared for 2 patients. We were told there was a very good support system, and it had helped with their autonomy, learning, and development. The initiative, supported by the practice placement team, received positive feedback and was presented at professional conferences.

The workforce workstream were reviewing the maternity and neonatal staffing to ensure alignment with service needs and community representation. There were planned actions to reduce workforce inequalities, strengthen the fetal medicine team, upskill Band 2 midwifery support workers to Band 3, develop a workforce strategy, review administrative support, and conduct a demand and capacity review to determine consultant staffing needs.

The service assessed and managed the risk of infection. Staff used equipment and control measures to protect women, themselves and others from infection. They kept equipment and premises visibly clean.

Infection risk was managed in line with current national guidance. There were effective systems to ensure there was thorough cleaning and decontamination of rooms following patient discharge or transfer. Cleaning records were consistently updated and showed all areas were cleaned regularly.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Managers audited compliance with infection control practices including hand hygiene, care quality assurance and cleaning. Staff were aware of audit results and told us compliance was addressed at handovers, team meetings and on their closed social media group.

Infection prevention and control audit data were displayed in ward areas. On Cedar Ward, the annual infection prevention and control efficacy audit showed a 100% score. Handwashing and environmental audit results from January to March 2025 ranged from 85% to 100%.

Staff we observed followed infection prevention and control principles including the use of personal protective equipment. We saw staff washed or gelled their hands in line with the 5 moments for hand hygiene and hand gel was available at the entrance to each ward area.

The service did not ensure medicines were stored securely. Resuscitation medicines required in an emergency were not stored safely in tamper-proof trolleys in contravention of Resuscitation Council (UK) guidance.

Women were at risk of harm from medicines being accessible and at risk of tampering or removal by unauthorised people. During the onsite assessment, we observed multiple instances of unsecured medicines, including in operating theatre 2 on the delivery suite, the epidural and emergency trolleys on the delivery suite, and the emergency trolley on Maple Ward. Additionally, the fridge outside the delivery suite was unlocked and contained medicines, and out-of-date medicines were found in the neonatal emergency trolley.

Although a keypad lock was installed on the entrance to theatre 2 on 29 April 2025 in response to concerns, the widespread presence of unsecured medicines elsewhere meant there was a lack of assurance for the service that all medicines across maternity services were safely stored or kept in tamper-evident containers. Following the assessment, the service ordered tamper-proof emergency trolleys to improve the security of emergency medicines.

The approach to some medicines management did not align with current evidence-based practice or professional guidance. For example, the fridge in theatre 2 was unlocked and contained a pre-drawn syringe of oxytocin that was undated, and no dose was specified. This was not in line with the National Patient Safety Alert issued in September 2024 regarding the risk of oxytocin overdose during labour and childbirth.

Not all medicines were stored safely. These concerns were raised with the service during our feedback meeting with senior leaders on 30 April 2025. A subsequent audit by the pharmacy team on 9 May 2025 found continued non-compliance. The delivery suite was 77.8% compliant, theatre 1 was 60% compliant, and theatre 2 was fully compliant. Non-compliance included unsecured medicine trolleys, medicines not locked away or kept in original containers, an unlocked epidural trolley in an unlocked theatre, an unlocked fridge containing medicines, and expired medicines. Pharmacy staff were supporting the service with regular audits and spot checks to improve oversight and ensure timely follow-up on actions.

Although there were processes to ensure medicines were administered as prescribed, staff did not always follow them. We reviewed 13 medicine records and found errors in prescribing and administering medicines. We also reviewed safety incidents between January to April 2025 and found 6 medicine errors including incorrect intravenous drug administration, wrong medication prescription and wrong medication to take home. A drug error was observed during the assessment when a midwife administered incorrect medication to a postnatal woman after checking with a non-registered staff member.

Women were appropriately involved in decisions about their medicines. We observed a midwife discussing pain relief options with a patient, including potential side effects and their impact on the baby, allowing the patient to make an informed decision.

There were appropriate arrangements for the safe management, use and oversight of controlled drugs, but not all checks were carried out. Controlled drugs were stored safely and securely with access restricted to authorised staff. However, checks were not always undertaken and recorded by 2 staff each day. On Cedar Ward, there were 7 days between January and April 2025 when checks were not recorded. Despite this, controlled drugs were in date and stock balances were accurate.

Staff told us they had reduced the delays in `to take out' (TTO) medication for patients on discharge. Staff sent a scanned copy of the medicine charts to the pharmacy which ensured women did not miss their regular medicines and there were fewer delays in dispensing the TTOs. Postnatal wards held a stock of TTOs, which could be dispensed by 2 midwives to support timely discharges.

There were patient group directives for pain relief which allowed certain medications to be administered without a doctor's prescription.