Birmingham Heartlands Hospital

On this page

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

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

At our last assessment we rated this key question as inadequate. At this assessment, the rating has changed to requires improvement

Following our previous inspection, the service was found in breach of legal regulations in relation to safe care and treatment and premises and equipment. The service has made some improvements and is no longer in breach of regulations relating to premises and equipment but remained in breach of the regulations in relation to safe care and treatment. While the rating has improved, more work needed to be done around safety. Women in triage were not seen in line with recommended timeframes by doctors, medicine prescribing and documentation from the medical staff required improvement, equipment checks were not always completed properly and there were midwifery staffing gaps.

However, risk assessments were consistently completed and used to identify and manage risks to women and babies. Leaders had improved oversight of staffing and deployed them more effectively to meet the needs of the service. Incidents were reported, reviewed and used as opportunities for learning, with actions shared to reduce the risk of recurrence. Women’s outcomes were monitored and demonstrated alignment with recognised clinical standards, supporting the delivery of safe care. These improvements showed the service had strengthened its approach to managing risk, learning from events and maintaining safe care.

We have not awarded this service a score for Safe.

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

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

The service promoted a positive culture of safety and learning, with effective systems to share learning across teams. Safety was a priority for the service and was embedded across all levels, involving both staff and people using the service. There was an open and transparent culture that encouraged learning from events that had caused, or had the potential to cause, harm to women or staff.

The team had acted following the previous inspection to make improvements to the safety of the service for women and their babies. There was a commitment to making improvements and learning; introducing changes carefully and thoughtfully, without rushing or becoming complacent. There was a supportive and much improved culture across the midwives and people were not afraid to speak up. We saw improvements in culture had led to a better learning environment.

The service used a range of approaches to share learning from incidents. These included governance newsletters, “listen, learn, share” discussions, weekly briefings, “message of the fortnight” communications and ‘real-time’ governance meetings. Lessons learned were also shared at team level, including during handovers.

The service had systems to ensure incidents resulting in harm were appropriately investigated by staff and used to drive learning and improvement. Where moderate or above harm was identified in reported incidents, the leaders co-ordinated a 72-hour review. This multidisciplinary process enabled incidents to be analysed promptly, with immediate learning identified and action plans developed. We reviewed three 72-hour reviews, which were detailed and demonstrated clear learning.

The Maternity Governance Matron reviewed all 72-hour reviews quarterly to identify any themes and recurring issues. Key issues from April 2026 report were:

• Documentation failures
• Escalation and senior review delays
• Non-adherence to clinical pathways
• Delayed recognition of deterioration
• Fetal surveillance and post-partum haemorrhage management deficiencies.

Thematic findings were shared with the relevant quality improvement groups as well as through maternity safety meetings and established governance forums.

Teams reflected on incidents and identified learning to support continuous improvement in maternity care. The service completed debriefings with staff immediately following unexpected or complex maternity incidents, involving the multidisciplinary team where possible. We reviewed 2 records of debriefings from June 2026, and they clearly identified what had gone well, areas for improvement and agreed actions to support learning and improve future practice.

The service had begun to embed processes to support the timely review of incidents and promote early learning. The service had recently identified the need to have a ‘swarm’ meeting. This approach, widely used in the NHS, enabled key staff to be brought together quickly to review incidents soon after they occurred. The first swarm was completed in May 2026, and staff reported this had been a positive experience. The swarm report demonstrated clear discussion regarding the outcome for the woman and identified learning for the team.

Staff understood the duty of candour. They were open and transparent and gave women and families a full explanation and apologised if and when things went wrong. The service reviewed compliance with duty of candour and reported this within the quality and safety report. In May 2026, there were 4 stage 2 duty of candour processes to be completed; all had documented monitoring plans. The service had strengthened the governance approach. All outstanding duty of candour required a weekly review through the governance and assurance oversight meeting to ensure they were on track.

There was effective learning from perinatal deaths and stillbirths, with learning identified, shared and used to drive improvements in practice. Staff learned from adverse outcomes and took action to reduce the risk of recurrence. There was clear evidence of learning from Perinatal Mortality Review Tool (PMRT) reviews. A multidisciplinary panel met weekly to review the care provided in cases of stillbirth and neonatal death, ensuring opportunities for learning were identified and explored. Learning from reviews was shared with staff through study days, forums and governance meetings to support improvements in practice.

There was a proactive approach to identifying learning and embedding improvements across the service. We reviewed a learning presentation from May 2026 which demonstrated how findings from PMRT reviews had been translated into actions for staff. Learning included reminders about the importance of regular check-ins with women during labour and the timely offer of appropriate pain relief. Staff were also reminded to escalate concerns promptly when women showed signs of sepsis, ensure effective handover when women moved between clinical areas, and liaise with safeguarding teams when women did not attend appointments on more than two occasions.

Incidents and complaints were shared in a timely way. 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 and complaints was shared through ‘message of the week’ which was presented at each handover, emails and governance newsletters. The message was changed weekly. The daily 9am huddle included the governance team who shared any incidents that had been submitted within the last 24 hours that needed to be highlighted. The huddle was attended by leaders of all departments cross-site. Meetings occurred cross-site to ensure there was shared learning from all incidents.

Managers told us staff were confident and proactive in reporting incidents. However, the service recognised the need to strengthen the timeliness of incident reviews, and the governance team was developing an improved strategy to address this. At the time of inspection, there were around 280 incidents overdue for review. Despite this backlog, the quality and safety team maintained oversight of risk. They reviewed all open incidents daily, escalated any identified safety concerns at the daily safety huddle, and provided updates through the daily real-time governance meeting to ensure risks were visible and acted upon promptly.

We observed an update from the governance team at the safety huddle on 3 June 2026, where 2 cases were identified as requiring rapid review and were escalated to managers. The maternity governance team were launching a weekly drop in for anyone who needed advice or support in completing or closing incidents.

Lessons were learned from safety incidents and complaints, resulting in changes that improved care for others. Staff gave examples of changes made following incidents. For example, there was an incident causing harm due to equipment not being available in the delivery room. The manager had devised a twice daily ‘room reset’ checklist for each delivery room to ensure all equipment was available and ordered replacement equipment where there were gaps.

Serious incidents were treated with priority. Thirteen maternity related serious incidents were reported at Heartlands Hospital during the period 1 May 2025 to 1 May 2026. Two of the incidents have been referred and accepted by the Maternity and Newborn Safety Investigations (MNSI) team for investigation, and 8 of the incidents were recorded as having a patient safety incident investigation under the NHS Patient Safety Incident Response Framework (PSIRF).

We reviewed 3 MNSI investigations and found the reports had clear action plans for the maternity team to make improvements to the service. For example, 1 woman had been delayed in her transfer from the maternity unit assessment unit to the delivery suite while in active labour. In response to this, the managers had implemented a paging bleep, to be carried by the Band 7 midwife on the delivery suite, for urgent escalation of cases. This had been implemented in May 2026, and the triage guideline had been updated to reflect this.

Women and staff were encouraged and supported to raise concerns, felt confident they would be treated with compassion and understanding, and would not be blamed or treated negatively for doing so. The service reported good compliance in investigating maternity complaints, with 93% completed within the 65-working-day agreed timeframe. Since April 2025 to March 2026, 87 complaints were received. We reviewed 3 complaint responses and found them to be detailed, clear and supportive.

The service demonstrated a good understanding of complaint themes and had taken appropriate action to address concerns, resulting in reported improvements in patient experience. The main themes identified from complaints related to pain relief, support during induction of labour, and communication. A further recurring concern was that some women did not feel adequately supported during the early (latent) phase of labour.

The service recognised that poor patient flow contributed to these issues, with some women waiting for a bed in environments that were not always appropriate, such as the maternity unit assessment unit (MUAU). In response, leaders had taken targeted action, including relaunching the latent phase of labour guideline and strengthening staff knowledge through drop-in education sessions and informational videos. The opening and use of Willow Ward (the new birthing unit for low-risk women) also supported improved flow and more appropriate placement for women. Following these interventions, the service reported a reduction in both formal complaints and requests for birth reflections, indicating a positive impact on women’s experiences.

To respond to themes from complaints, midwifery care assistants completed walkarounds on the delivery suite once every shift to check on women undergoing induction of labour. These walkarounds included comfort and environment checks, with any concerns escalated to the midwife as required. Staff reported this approach supported improved patient experience and helped to reduce complaints.

Learning was shared across staff groups. Students on the preceptorship programme told us they spent 2 weeks working with the clinical governance team as part of their rotation. They said they valued this experience as it provided a good insight into incident management processes and how actions were implemented following learning.

We scored the service as 2. The evidence showed some shortfalls. There remained some concerns with timely medical reviews by consultants and triage not meeting national standards. The service was addressing this but needed to make more rapid progress. There were also concerns with some of the documentation by medical staff.

However, the service worked with people and healthcare partners to mostly establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

The service had implemented a nationally recognised maternity triage system. Compliance with the Birmingham Symptom Specific Observation Triage System (BSOTS) standards were improving but remained below target. BSOTS sets a target of 15 minutes for initial triage. Compliance with this standard improved to 59% in May 2026, demonstrating an upward trend from 38% in October 2025. The service completed an observational audit of triage as part of the ongoing improvement work to meet the BSOTS and recognised there were sometimes clinical interventions affecting compliance with these standards. For example, asking for a urine sample before initial triage. These findings had been shared with staff. Leaders had also identified that delays most frequently occurred during afternoon periods and had acted to resolve this by securing funding for an additional midwife to cover a daily late shift.

Triage guidance was up to date. The service had updated its triage guidelines in line with Royal College of Obstetricians and Gynaecologists guidance and the BSOTS pathway. Staff had received training on the revised process. Compliance was monitored through weekly spot checks of 2 sets of patient records. Managers had also developed an audit plan and were planning a more detailed review.

However, women were not always reviewed by doctors in line with expected standards. The service was required to provide triage cover 24 hours a day, 7 days a week, with a target compliance of 85% of women reviewed within the recommended timeframe. The data reviewed between June 2025, and May 2026 showed 55% of women were seen by a doctor within the recommended timeframe. This was below the expected 85% standard. Staff told us there was not always a doctor available to see the women within the expected timeframe. We were told problems mainly occurred when there were shortfalls in staff or the delivery suite was busy. This was mostly at night or at weekends where triage cover was provided by 1 doctor who was also supporting the labour ward.

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 Sunday. This allocation exceeded the Royal College of Gynaecologist (RCOG) recommendations for medical staffing in triage, but women were still experiencing delays. Staff in the day assessment unit told us they had similar issues and at times there were long waits for women to be reviewed by the doctors.

Flow co-ordinators kept an oversight of delays and chased doctors for reviews. Managers told us that while they were aware their medical workforce was in line with RCOG it was under review by the operational team. There was a triage working group which had several actions to improve compliance including: observation of activity and process, ring fencing staffing when in escalation, refresh training for all staff which had been completed and monitoring telephone compliance. At our previous inspection in April 2025, we found this was an issue and it had decreased further from 71% to 55% of women seen on time by the doctor on this inspection.

However, leaders were taking a proactive and collaborative approach to improving triage, with a focus on targeted, achievable changes. There was a multidisciplinary triage workstream to drive improvements. Leaders described a focus on making small, practical changes to achieve meaningful impact, including using system functions to improve follow‑up of women who did not attend appointments. The service had also supported shared learning by arranging for 2 matrons to visit a high‑performing triage department.

Delays in assessment meant some women left before being seen. The triage telephone team contacted women the following day who had left triage without being seen, to provide follow-up and review of any ongoing needs or concerns.

The service was mostly compliant with National Institute for Health and Care Excellence (NICE) Maternity staffing red flag events for midwives, although was not meeting local standards. There was evidence of ongoing improvement and responsive action to address identified delays. Women were generally assessed by midwives within recommended timeframes in line with their clinical risk, with triage provision available 24 hours a day, 7 days a week. NICE guidance recommends that 90% of women receive an initial assessment within 30 minutes of arrival. Service data between March 2026 and May 2026 showed compliance rates ranging from 84% to 89%, indicating performance was slightly below the expected standard, but had started to improve throughout the year.

The service had oversight of the improvements to be made to the telephone triage system. May 2026 data showed 67% of calls were answered and 24% were abandoned by the caller before being answered. The data showed while call volumes fell in the evening and overnight, the ratio of calls answered to abandoned during this period was significant. The team recognised this needed work and was going to be a focus within the triage working group.

Data was provided for ‘real time’ monitoring. There was a dashboard to monitor triage compliance, and it was reported monthly by matrons to leaders. Leaders advised that medical staff did not always complete or close documentation, and that the new dashboard would support improved compliance.

The service recognised the impact of missed appointments on safety and had implemented a structured approach to improvement, with early evidence of progress. Work underway with women who did not attend pre-arranged appointments had seen improvement rates of around 5% for women who were not attending for a myriad of reasons. The service identified ‘did not attend’ (DNA) as a recurring theme in patient safety incidents and established a dedicated task and finish group, led by the deputy chief nurse, alongside an existing quality improvement group. An audit highlighted issues with communication and administrative processes, with over 2,000 missed appointments between January and March 2026 and peak DNA rates between 9am and 10.59am. Following targeted actions, including more flexible appointments and improved communication such as text reminders, the service reported a 3% improvement. Further actions included plans to introduce an app for women and to ensure preferred appointment times were agreed at booking.

Learning from Perinatal Mortality Review Tool (PMRT) reviews was used to drive improvements in triage, although delays in assessment and admission were identified in a small number of cases. PMRT is a national, standardised process used to review stillbirths and neonatal deaths to identify learning and drive improvement. PMRT reviews of 11 cases identified 3 where aspects of care may have influenced outcomes, including delays in midwifery or obstetric triage assessment and delays in admission. These delays were present across all 3 cases but were considered to have potentially contributed to the poor outcome in 1 case. Findings were shared with the triage quality improvement group and were the basis for ongoing improvement work.

The service had made significant improvements in reducing delays in induction of labour (IOL) through effective guideline implementation and oversight, although some women still experienced delays. At our previous inspection in April 2025, we found significant delays in IOL, primarily due to limited bed availability. At this inspection, despite no increase in capacity, the service had implemented a new IOL guideline in March 2026, which had significantly reduced delays. The guideline introduced defined gestational windows. This was a period within their pregnancy where it was safe for them to be induced. By introducing these, it had improved prioritisation, flexibility and management of women’s expectations.

Outstanding IOL cases were reviewed at daily huddles, with women prioritised by gestational age. Staff reported these changes had made a significant difference, with fewer delays and a reduction in women requiring daily monitoring. Delays remained on the risk register with escalation processes including through the Local Maternity and Neonatal System (LMNS) where women could be diverted to another service if safer to do so.

Data demonstrated sustained improvement. Prior to implementation, an average of 11 women were admitted daily, with around 6 experiencing delays. Following the April 2026 changes, admissions reduced to an average of 6 per day, with approximately 0.5% experiencing delays, indicating improved timeliness and efficiency.

Women’s investigation results, such as blood tests, were not always reviewed promptly by staff. We observed this was highlighted as an incident by the team and discussed in the daily huddle and a doctor was assigned to review the backlog within the afternoon. Staff told us this happened if they were short staffed, but resolutions were found to improve the backlogs.

Some documentation by medical staff was not consistently clear or comprehensive, impacting the clarity of care planning and communication. This reflected themes from the May 2025 Governance Newsletter ‘case of the month’, which highlighted unclear documentation and inconsistent recording of communication between doctors. These concerns had already been identified within ward areas, and feedback had been provided to medical staff. However, this had not resulted in sufficient or sustained improvement. We raised this with senior leaders, who responded by arranging a series of documentation workshops. These were intended to support improvements in record-keeping, emphasise the importance of clear and effective communication, and signpost staff to the appropriate systems and locations for documenting patient information.

The service had effective systems to monitor and respond to operational pressures, with evidence of timely escalation and co-ordinated action to maintain patient safety. The service submitted data 6 times a day to generate an operational pressure escalation level (OPEL) rating. Senior leaders held twice-daily huddles to review pressures, risks and implement actions to maintain patient safety, with additional meetings convened during higher escalation levels. For example, on 3 June 2026, when the service was at OPEL red, indicating severe pressure, managers arranged cross-site support, including diverting women to Good Hope Hospital to manage flow issues at the Heartlands site. An additional escalation meeting was held at 11.30am to review actions and seek improvement in operational pressures.

Information about women was communicated effectively between health professionals. We observed 3 handovers between staff, including the doctor’s handover, and found they were structured and staff were engaged.

The service had established effective daily multidisciplinary communication processes, which improved team awareness, collaboration and proactive risk management. A daily 8.30am ‘team of the shift’ meeting brought together departmental leads to discuss each of their areas including staffing, discharges, risks, safeguarding and medical cover. Team of the shift had been introduced following our previous inspection, and it was spoken of positively by staff. In focus groups we held with staff at the end of March 2026, staff reflected on how the daily meeting gave them a valued insight into the pressures of their colleagues. They talked about how it enabled them to find quick solutions to problems and work more strategically and cooperatively. Observations of a meeting on 2 June 2026 showed staff actively identifying shortfalls, risks and support needs for the day. Leaders also used the meeting to reinforce key messages to teams.

The service consistently used the SBAR (Situation, Background, Assessment, Recommendation) framework, a key risk management tool for communicating information about people between health professionals. We found at the previous inspection, SBAR was not consistently used and in all of the notes we reviewed it was not completed. On this inspection, we reviewed 10 sets of notes and found this was consistently completed. The service had completed several documentation workshops within the previous 12 months including training on the use of SBAR framework. Leaders told us SBAR had improved considerably but still felt there was work to do to maintain high standards.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately. However, some staff training needed to be updated to meet trust targets.

The service ensured people were safeguarded from abuse and avoidable harm. The service worked with people to understand what being safe meant to them and the best way to achieve this. Staff understood their responsibilities to protect people from abuse, and the service worked collaboratively with other agencies to do so.

Training data showed 100% of non-clinical staff had updated their level 1 safeguarding and prevent training. All clinical staff were required to complete and update level 3 safeguarding adults and children training. However, compliance was variable, ranging from 75% on Eden Ward to 100% on the Day Assessment Unit, with 7 of the 10 areas not meeting the trust’s compliance target. Medical staff compliance to update their training was lower, with 72% of consultants and 68% of resident doctors having completed the required updates. The trust had recognised this gap having introduced an additional level 3 safeguarding training module in January 2026. A remedial action plan was underway to improve compliance, with a target of achieving 90% completion by September 2026.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. There was a clear safeguarding policy and pathway which was accessible to staff. All staff had the information available to be aware of how to make a safeguarding referral and who to escalate concerns to. The maternity safeguarding team attended daily huddles and provided updates to leaders on any potential safeguarding cases. Safeguarding cases were a priority when leaders were allocating staff to look after women.

Staff were able to contact specialist teams for advice, support and guidance. Community midwives referred women antenatally to the safeguarding team, who continued to support them during their hospital stay. Plans were sent in advance with a thorough assessment if women needed to remain on the delivery suite. The specialist teams also provided training and supervision as needed. We observed a complex case of safeguarding on the ward and the staff demonstrated clear understanding of safeguarding and protecting individuals and working collaboratively with partners.

The service had a baby abduction policy and staff participated in practice drills. Staff were familiar with the policy, ward areas were secure, and doors were monitored. The service had recently started fitting newborns with electronic tags on the labour ward, whereas previously they were fitted on the postnatal wards. These prevented them from being removed from the building as doors remained locked if a tagged baby was taken to the door. Tags were removed when the mother and baby went home.

Women were supported to understand their rights, including those under the Mental Capacity Act (MCA) 2005 and the Equality Act 2010. We reviewed the care of a patient detained under the MCA on the labour ward; a mental health nurse remained with the patient alongside a midwife, and records showed care was appropriately managed. There was an onsite mental health liaison team who attended the service when support was required.

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

However, some women were not cared for in the optimal setting due to bed pressures. There needed to be improvement in the digital systems to enable staff to have timely and more convenient access to women’s records. Some risks for women possibly not associated with their pregnancy were not managed well enough.

Women mostly received treatment within agreed timelines and national standards. The triage process followed evidence-based practice and women were graded in accordance with the seriousness of their presenting complaint. There was a colour-coded scale to give a visual for those women needing more urgent review. There were 3 triage midwives at busy times, but there were delays at peak times and plans were to introduce a fourth midwife onto the late shift; this would bring down waiting times for women.

Women were informed about any risks and how to keep themselves safe. Risks were assessed, and women and staff understood them. Staff ensured risk assessments were completed, 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. We reviewed 10 sets of notes and found risk assessments were consistently completed.

Staff effectively used recognised early warning tools to identify and respond to deterioration, with consistently high compliance, although there was some variation in timely obstetric review following escalation. Staff used nationally recognised tools to identify risks of deterioration in women and babies, including the Modified Early Warning Score (MEWS) for women and Newborn Early Warning Scores (NEWS) for babies. These were consistently recorded across all records reviewed. Monthly MEWS audits demonstrated sustained high compliance, with over 95% completion within 12 hours postnatally and 98.5% compliance reported in May 2026. Compliance with escalation of MEWS was consistently high, with 100% compliance reported in May 2026. However, compliance with obstetric review following escalation was lower, ranging between 88% and 89%.

The ‘fresh eyes’ approach for electronic fetal monitoring was implemented in line with NICE guidance (NG229), requiring hourly in‑person review of cardiotocographs (CTGs) by a second clinician. We reviewed 10 sets of records and found the process of the second review consistently completed. During the inspection, we observed labour ward co-ordinators undertaking and recording ‘fresh eyes’ reviews throughout their shifts, with completion clearly displayed on the ward whiteboard. However, audit results indicated that further improvement was required for the compliance to always be consistent. The service monitored the percentage of ‘fresh eyes’ reviews completed within one hour, with results showing a steady improvement from 80% in January 2026 to 97% in April 2026, before decreasing to 84% in May 2026.

There was improved categorisation and escalation of CTGs. During our previous inspection we found CTGs were incorrectly categorised and were not escalated in a timely way. The service had implemented actions to raise the profile of fetal monitoring and ensure improved compliance. There was a team of fetal surveillance midwives who led a quality improvement workstream to drive the improvements. The service provided an annual fetal monitoring surveillance day, with high levels of compliance across staff groups, ranging from 88% to 93%. We observed a positive example of delivery suite staff appropriately escalating concerns regarding a CTG. The midwife was not satisfied with the consultant’s initial decision and requested a review by the fetal surveillance midwife. Following a joint discussion with the consultant, the management plan was revised to proceed with a caesarean section.

The service provided ongoing intrapartum documentation workshops to support staff with record keeping. ‘Ask me’ badge had been introduced in November 2025 for Band 6 midwives to promote escalation and access to advice where the Band 7 co-ordinator was not immediately available. The campaign had been reintroduced in March 2026 following a slight decrease in compliance. Fetal monitoring champions were visible within clinical areas and delivered regular fetal surveillance workshops, supporting real-time learning and practice.

The fetal surveillance team reviewed information from incident reports, ATAIN (Avoiding Term Admissions into Neonatal Units) and the Perinatal Mortality Review Tool (PMRT). They identified themes and assessed whether cardiotocographs (CTGs) had been correctly classified and appropriately escalated. PMRT is a national, standardised process used to review stillbirths and neonatal deaths to identify learning and drive improvement. The team reported improvements in CTG classification and escalation. Where further improvement was required, action plans were developed and fed into the quality improvement workstream to support sustainable change.

Leaders understood that problems with its digital systems could affect safe care and were working to improve this. Staff told us that limits with their digital systems made it harder to use the central monitoring system, especially for viewing CTG recordings across the service. This meant staff could not always review care quickly or work together as effectively, which could delay decisions and communication. For example, during handover, doctors could not access a woman’s CTG at that time, which meant they could not make an immediate clinical decision. The service recognised this and said digital systems needed to improve to support safer care.

Risk assessments relating to care were person-centred, proportionate and, where possible, regularly reviewed with women. At our previous inspection, we identified concerns that women were placed at risk of harm from postpartum haemorrhage (PPH) and major obstetric haemorrhage (MOH) due to inadequate risk assessments and delays in recognition. At this inspection, we found the service had taken action to address these concerns.

There was good compliance with PPH risk assessment. Leaders had re-launched the PPH risk assessment, supported by additional staff training, and had transitioned the assessment to a digital format. The assessment was completed at key stages of the pathway: antenatally, again between 34 and 36 weeks’ gestation (a new stage), and on admission in labour. Since the re-launch on 11 May 2026, the service had undertaken weekly audits of risk assessment completion rates, which demonstrated 100% compliance. Managers had also introduced a ‘blood loss’ check to ensure this was consistently documented for every patient. This formed part of the baby notes checklist and was reviewed by the Band 7 coordinator to ensure completion.

Incidents relating to PPH remained the most reported theme. However, leaders told us they anticipated improvements following the introduction of the antenatal checklist at 34 to 36 weeks in May 2026. This aimed to identify and optimise risk factors, such as low iron levels, prior to labour, with the intention of reducing the incidence of haemorrhage. Ward staff felt low iron haemoglobin levels were not always acted on antenatally which meant women were more at risk of a haemorrhage during labour. We reviewed a Perinatal Mortality Review Tool (PMRT) case which showed a low haemoglobin had not been acted upon antenatally. A working group had also been established to strengthen the completion and management of antenatal risk assessments.

There was good compliance with the theatre safety checklist. At our previous inspection, we found staff put women at risk of harm due to lack of engagement with the operating theatre World Health Organisation (WHO) surgical safety checklists. At this inspection, we found staff were engaged in the WHO checklist. The service was in the process of implementing an updated WHO checklist which was in line with national guidance. The theatre team conducted a briefing at the start of each list. During observation on 3 June 2026, this was found to be well attended, informative, and inclusive. Patient risks were discussed collaboratively, with clear plans made regarding case order and postnatal care, and close coordination with ward teams ensured bed availability or contingency planning where needed.

Record management from the midwives was good. In all 10 sets of notes we reviewed, we found handovers, risk assessments and fresh eyes reviews were all completed. This was a significant improvement from the last inspection.

The service monitored compliance with the sepsis pathway and had improved performance over time. Compliance with starting the sepsis 6 bundle within 1 hour increased from 80% in December 2025 to 100% between February and April 2026. A time and motion study identified a delay of around 6 minutes in gathering equipment, which led to the introduction of a sepsis grab bag. Audits showed 100% compliance in sepsis screening, completion of the sepsis 6 bundle, antibiotic administration and appropriate care for babies. The service identified areas for improvement in confirming the diagnosis of sepsis and identifying the source of infection and had actions to address this.

Staff had the skills, training and support needed to provide safe care for women with higher levels of clinical need and to respond effectively to obstetric emergencies. There were 2 high dependency beds on the labour ward. Women in these beds were always cared for by midwives who had completed their enhanced maternal care training. Practical Obstetric Multi-Professional Training (PROMPT) and Clinical in Practice Programme training had been introduced in May 2026 for all staff. These were structured, evidence-based training programmes designed to improve safety, teamworking and outcomes for women and babies. They focused on emergency obstetric situations including simulation-based scenarios. Training compliance for PROMPT was high across staff groups, with 85% to 97% completion rates.

Staff liaised with mental health colleagues as required. Perinatal mental health support was available 24 hours a day, 7 days a week. Staff explained when and how they could seek assistance to support women with mental health needs.

Some women were not always cared for in appropriate areas due to pressures on capacity for available beds. This affected patient flow across the departments and resulted in some delays, although reducing, for women awaiting induction of labour (IOL) and planned caesarean sections. The service induced up to 6 women per day. The induction list was reviewed twice daily at safety huddles, where individual plans of care were developed for women experiencing delays. Consultants also reviewed these women daily and prioritised them based on clinical need. The IOL guideline had been rewritten, supported by a quality improvement project aimed at improving efficiency. The service reported a reduction in delays following the introduction of induction pathways based on gestational age ranges.

Some risks for women were not always detected and managed well. We observed the medical handover and a patient, who had a head injury, had not been referred for further management by other teams. Another patient had limited discussions around their mental health despite risks of the medication they were on was known to impact mental health.

The service had improved the care of women with diabetes through strengthened specialist input and multidisciplinary working, although workforce capacity continued to limit further development. The service provided specialist clinics, including diabetes clinics, to support women. A weekly multidisciplinary team meeting reviewed high‑risk women and their care plans. The service had recently separated clinics for type 1 and type 2 diabetes and gestational diabetes, which improved focus and management for women.

The Saving Babies’ Lives quarterly report (January to March 2026) showed improvement in diabetic care processes, including achieving targets for HbA1c monitoring. HbA1c monitoring is a blood test that shows a woman’s average blood sugar levels over the preceding 2 to 3 months. At the previous inspection, the service was not meeting national guidance and lacked sufficient specialist midwives. At this inspection, risks had reduced and care was being delivered, although the need for additional specialist midwives remained on the risk register. Limited specialist midwife capacity meant there was less time to support further quality improvement work.

Action was taken when women or their families had concerns about their care or treatment. The maternity service introduced Martha’s Rule in 2025. Martha’s Rule is an NHS England patient safety initiative. It provides patients and families with a way to seek an urgent review if theirs, or their family member’s, condition deteriorates and they are concerned this is not being responded to. Since March 2025, the rule had been invoked by families 4 times. No changes to practice were made as there was no deterioration found in the woman or baby.

We scored the service as 2. The evidence showed some shortfalls. The environment was not able to accommodate the number of women needing to be seen, so this was leading to some concerns around safety at times. However, the service detected and controlled potential risks in the care environment.

Staff did their best to keep all women safe, but the volume of women using the service meant there were risks to safety at times. The design of the maternity environment followed national guidance but there was not enough space to deliver care to women. The unit was built originally for 3,500 births each year, and the service now had around 6,500 births per year. A lack of space in the antenatal wards resulted in some antenatal women being accommodated in the delivery suite, reducing space for women in labour.

The service had a significant number of incidents reported due to poor flow, such as women waiting for a bed which resulted in delays to induction of labour. This was on the service risk register and there was an improvement project to address the capacity on the antenatal wards.

Some areas of the maternity department needing updating. For example, there was a very small staff room on delivery suite at which facilitates the medical handover, team meetings and the area where the staff take their breaks. There is currently no dedicated space for clinical handover or multidisciplinary team work on the delivery suite. Adequate space was needed for handovers, reviews of women with complex needs which includes using centralised clinical monitoring systems.

Women were cared for in safe environments which were locked and monitored. The unit was fully secure, with monitored entry and exit points in each area. There were security guards who monitored the front entrance 24 hours a day 7 days a week.

Equipment was not always available to deliver care and treatment, and safety checks were not consistently completed. The new delivery suite ward manager had placed orders for equipment that was not available. They had also identified that neonatal trolley checks were not being completed. Compliance was poor in April 2026 at 57%. The manager created videos showing staff how to complete the checks and gave them feedback and compliance improved to 90% in May 2026.

Equipment checks were not always completed. We found on maple ward that checks were completed but the equipment was not actually checked. We found discrepancies with equipment within the trolley and what the checklist said. For example, the postpartum haemorrhage box said it had been checked daily but it was found to be empty. On delivery suite, the emergency trolleys were checked fully every Tuesday, the tag number was checked daily. The manager found there were missing checks in May 2026 and added a box onto the Band 7 coordinator daily checklist as a prompt to ensure it was completed.

The service had taken action to improve equipment safety through a structured checking process, although gaps in equipment availability were identified and were being addressed. The delivery suite had implemented a ‘room reset’ process whereby each delivery room was checked twice daily and following patient discharge. This was introduced in response to an incident where essential equipment was not readily available during an emergency. The room reset checks were recorded electronically. Findings from these checks identified there was insufficient equipment available to ensure each room was fully and safely equipped. The manager confirmed that additional equipment had been ordered and that a monthly audit process would be implemented to monitor equipment availability.

The estate’s workstream priorities remained the same as at our previous inspection and included 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 layouts within the service.

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

We scored the service as 2. The evidence showed some shortfalls. Although much improved, there were still some gaps in rotas for qualified, skilled, and experienced midwifery staff and triage services were not always covered in a timely way by doctors overnight. There were high levels of sickness, although this was reducing. There were some concerns around support for medical staff after upsetting incidents.

Staffing levels and skill mix were managed to ensure women received consistently safe, good-quality care that met their needs but there were still gaps in some of the rotas. Midwifery staffing remained high on the risk register. Where gaps occurred, managers redeployed staff based on activity levels and patient acuity across clinical areas. Acuity is the assessment of a woman's clinical needs and the corresponding level of care required. Staff who could be redeployed were identified with an ‘R’ on the rota, which improved transparency, predictability and promoted equity across teams. One midwife told us, while it felt safe, they did not always have time to care and go above and beyond for women.

Staffing had improved since the previous inspection. However, workforce planning indicated the service did not yet have sufficient midwifery staff to meet demand safely. At our previous inspection, midwife shortfalls impacted on the quality of care. At this inspection, staffing levels had improved. The vacancy rate in April 2026 for midwifery staff was 8%. Leaders told us this had improved to approximately 3% with new staff joining over the coming months. The vacancy rate was much higher for midwifery care assistant staff at 26%.

Leaders told us where there were issues within the service, this was due to demand and capacity rather than staffing levels. However, they had recently completed their Birthrate Plus: a workforce planning told used to determine safe staffing levels based on the complexity of women’s needs and workload. This showed the service needed 43 extra midwives to ensure safe delivery of care.

Leaders had effective systems to manage safety and capacity across sites and respond to changes in acuity. 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. Staff told us the safety and capacity midwife roles had had a positive effect in uniting both midwifery-led units and ward areas on site. They gave an insight into the real time challenges of staffing and acuity at any given time. 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.

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 2 June 2026, and staff highlighted shortfalls in staffing, potential discharges, risks and doctor cover in all areas. The service did not use agency midwives. However, there had been a noticeable reliance on internal bank staff to support safe staffing levels. The managers were aiming to reduce bank usage by 15%. The highest levels of usage in February 2026 were Maple ward at 33% and Cedar at 26%.

The service was consistently worse than the trust target of 4% for sickness. Data showed this was improving; it had reduced from 8.2% in December 2025 to 6.2% in February 2026. The most notable theme for long term sickness was stress and anxiety. However, this was being actively managed by ward managers.

Midwifery staffing levels were managed in line with national standards although data showed some delays in care. The service monitored red flags in accordance with National Institute for Health and Care Excellence (NICE) guidance, with 186 reported during this period. Red flags were nationally recognised warning signs that staffing levels may be unsafe and could impact care. The most frequently reported red flag was delayed or cancelled time-critical activity, accounting for 84% of incidents. All red flags were reviewed in the intrapartum monthly matron’s report. We reviewed May 2026 report which analysed the 4 red flags submitted in April 2026 and found none were attributable to midwifery staffing.

Midwifery staffing levels did not consistently meet acuity requirements. However, there was evidence of improvement and active management of staffing pressures to support safe care. Birthrate Plus data showed 1-to-1 care during labour was achieved in 100% of cases between September 2025 and February 2026, in line with standards. Birthrate Plus is an assessment produced on the number of midwives needed in each area to meet the needs of the women based on the minimum standard of 1-to-1 care in labour for all women in the higher needs categories. The tool is completed 4 hourly.

Data showed between September 2025 and February 2026 the service met the acuity 37% of the time, 50% of the time they were up to 3 midwives short and 13% of the time they were over 3 midwives short; the national benchmark was to meet the midwifery staffing levels 85% of the time. The service acuity had improved to 53% in April 2026 which was a significant improvement on previous months. The primary driver was staffing vacancies, short-notice sickness and shortfalls in support-staff cover. There was daily operational oversight of these pressures and staff felt these were mostly well managed with mitigations deployed to maintain safe service delivery.

Senior managers were able to keep oversight of the department without being pulled away to deliver direct care. The labour ward co-ordinator was supernumerary at the start of the shift 100% of the time between September 2025 and February 2026.

The service had effective systems to monitor staffing and respond to pressures, supported by strong partnership working, although staffing challenges remained. The service used an acuity tool to assess safe staffing levels across all shifts and departments, with data submitted four times daily to generate an operational pressure escalation level (OPEL) rating. This information was shared across the Local Maternity and Neonatal System (LMNS) and discussed in staffing meetings.

A first contact matron was available daily to support and address issues, including ensuring women awaiting induction were reviewed and monitored. We saw this worked well in practice, with LMNS partners supporting each other when services were at OPEL red. There was clear evidence of strong collaboration within the LMNS. Senior leaders held twice-daily meetings to review acuity, staffing and risks, and staff were redeployed when needed to maintain safe care.

Medical staffing levels for triage met the guidance but the service was still not being covered as required at all times, although there was no evidence of harm. At the previous inspection, medical staffing in triage was not sufficient to consistently provide timely care, and a warning notice had been issued. At this inspection, the number of staff had been increased, but the organisation of cover had not been safely resolved.

There was no dedicated doctor for triage overnight, and women were not always seen within recommended timeframes. During the day, 2 doctors were allocated to triage between 9am and 8pm, which exceeded Royal College of Obstetricians and Gynaecologists (RCOG) guidance for in-hours cover. However, overnight the service relied on on-call doctors who also covered the delivery suite and postnatal wards. Data showed medical staff attended triage within the expected timeframe in an average of 55% of cases. This was worse than our previous inspection where 71% of women were seen at triage in the recommended timeframe.

Maternity leaders told us they were assured these delays were not causing harm to women and babies. Triage activity was tracked on a dashboard and reported on monthly. The flow co-ordinators chased doctors and escalated to consultants when required. There was a triage working group and any incidents were examined in governance meetings.

Medical staffing was generally good within the maternity service, although there were gaps in the consultant workforce. The service regularly reviewed staffing requirements. An additional 8 consultants were required to meet the planned establishment; 4 of these posts had been recruited into with start dates. 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. 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. There was a 5.6% vacancy for resident doctors (registrar level) and 3.8% vacancy for senior house officers.

Staff reported consultants were mostly accessible and approachable. Although some resident doctors reported there was not always good support for them after difficult incidents. One described a difficult incident that had happened overnight and they were not offered any further support or able to attend debrief meetings and were expected to return the following night shift.

Staff had appropriate opportunities to maintain competency and were supported to work flexibly across the service. When midwives progressed to a Band 6, they were deployed across 2 areas within the service. This approach maintained clinical skills and supported midwives working in different areas to have the competence and experience to do so safely. Staff told us they liked this as it gave them appreciation for different areas and felt they understood associated pressures better.

Staff were appropriately trained to meet the needs of women, with clear systems to ensure skilled staff were available to support higher acuity care. Staff received training relevant to their roles. The delivery suite required a high dependency trained midwife to be present on every shift, which was clearly identified at handover and through the use of a badge to highlight their role.

Recruitment and performance processes were fair and regularly reviewed to provide equity. This was a focus for the Equality Inclusion and Diversity Midwife who was involved in the shortlisting process to ensure recruitment was fair. A Band 5 member of staff told us they had been involved in the Head of Midwifery recruitment process by sitting on the interview panel and felt included in the decision-making.

Staff received support through supervision, appraisals, and professional development. Staff told us the preceptorship programme was excellent, and one described it as “super supportive”. One Band 5 midwife told us there was “fantastic support and training” and they felt they “can develop and thrive”. Staff told us they felt retention rates had improved because of the preceptorship programme preparing Band 5 midwives effectively. Clinical practice support midwives were assigned to support less experienced staff. Band 5 midwives told us they were invaluable.

Leaders supported staff wellbeing and learning through an effective advocating for education and quality improvement programme (A-EQUIP). The professional midwifery advocate (PMA) team provided restorative clinical supervision, coaching and advocacy to maternity staff. Staff accessed support for wellbeing, career development, return to work and raising concerns. The PMA team also midwifery supported staff involved in safety incidents and contributed to quality improvement, education and inclusion initiatives. Staff reported feeling heard and supported, and leaders demonstrated how feedback and learning were used to improve staff experience and strengthen the safety culture.

Systems were not always effective in ensuring equitable access to training and development opportunities for all medical staff, although this had been recognised to an extent. Medical staff raised concerns that some training provision was not equitable, particularly between trust-employed doctors and trainee doctors. Trainee doctors reported having regular scan sessions, for example, and feeling well supported, whereas trust-employed doctors said they did not feel supported and did not have access to regular training sessions.

We raised these concerns with the senior leaders, who told us they were committed to ensuring equitable access to training, educational support and career development opportunities for all doctors within the service. However, this needed to be better communicated with medical staff. Managers demonstrated a comprehensive approach to improving support for trust-employed doctors. This included the allocation of educational supervisors, access to Royal College of Obstetricians and Gynaecologists portfolios and assessments, baseline competency evaluations prior to rota progression, provision of appropriate training opportunities, and regular review of training provision and rota equity.

Staff at all levels had opportunities to develop, and poor performance was managed appropriately. Leaders had introduced a deputy ward manager role for 7.5 hours per week in each area. This provided Band 6 staff with development opportunities and supported effective succession planning for future ward manager roles. Leaders were also developing induction booklets for labour ward co-ordinators and ward managers. They were also allocating additional tasks to the labour ward co-ordinator roles such as audit and review of the Perinatal Mortality Review Tool system to improve their awareness and leadership skills.

There was good feedback from students placed at the service during their training – and the department had the most students in the country respond to the survey. The service participated in the 2025 National Education and Training Survey for midwife students. All midwifery students who responded would recommend the service for care of family and friends and 87% would recommend it for training.

There were good opportunities for students to learn skills in responsibility. The service had a ‘student-led’ postnatal ward where the students took charge of the women and were overseen by the Band 5 and 6 midwives. It had been rolled out across both Cedar and Maple ward.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were clear roles and responsibilities for infection prevention and control. Staff used equipment and control measures to protect women, themselves and others from infection. They kept equipment and premises visibly clean.

Women were protected, so far as reasonably practicable, from the risk of infection as premises and equipment were kept clean and hygienic. There were effective systems for thorough cleaning and decontamination of rooms following patient discharge or transfer. Records were consistently updated and showed areas were cleaned regularly.

There was an effective approach to assessing and managing the risk of infection, aligned with current national guidance. Managers audited compliance with infection control practices including hand hygiene and environmental audits. Audits results we saw were mixed. For example, on delivery suite the environmental and handwashing audits were above 90% but the peripheral venous cannula audit was 50%. Actions included reminding midwives to document the removal of the cannula.

The service had audited its surgical site infection rate. It reviewed 650 women who underwent a caesarean section between January and March 2025. There was an overall surgical site infection rate of 11.1% highlighting the need for ongoing infection prevention strategies. The women were found to have a higher risk profile, meaning they had a high Body Mass Index or higher diabetes prevalence which contributed to a higher infection rate. The audit had recommendations for the service to implement to reduce the risks of infection. We requested the most recent audit, and this was from early 2025 and had not been repeated despite high levels of surgical site infections.

We observed most staff following infection prevention and control practices. Most 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. However, on ward round, we saw not all doctors washed their hands after contact with women.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met women’s needs, capacities, and preferences. They did not always involve women in planning.

Prescribing practices did not consistently ensure the safe prescribing and administration of medicines. We reviewed 14 medicine administration records. Staff did not always record the route of administration when medicines had been prescribed with more than one route available, such as oral or intravenous administration on the same prescription. As a result, it was not always clear which route had been used. This meant medicine administration records were not always complete or accurate and did not consistently reflect the care people had received. However, the records showed most people received their medicines as prescribed. Allergy status was recorded on all medicine records reviewed, which helped ensure known allergies were clearly identified and supported the safe prescribing and administration of medicines. Women's weights were also documented, supporting the safe calculation and prescribing of weight-based medicines.

Records relating to the prescribing of antibiotics were not always complete, and prescribing instructions were not always clear. We found gaps in antimicrobial stewardship practices. The reason for prescribing antibiotics was not always documented on medicine administration charts, and, in some cases, no indication was recorded in the woman’s clinical notes. Some antibiotic prescriptions contained unclear or poorly written instructions. This meant staff could not always demonstrate that antibiotic prescribing was in line with the trust's antimicrobial guidelines, reducing assurance that antibiotics were being used appropriately and safely.

We raised these prescribing issues with the senior leadership team who recognised the need for immediate improvement. In response, leaders outlined a series of actions. These included enhanced prescribing education delivered by the pharmacy team; reinforcement of safe prescribing training at induction; review and strengthening of audit processes with improved governance reporting; and reminders to staff of their professional accountability. In addition, there were plans to include maternity services within the trust’s digital prescribing strategy to further improve safety.

Medicines were generally stored securely, but medicine storage arrangements did not always support the safe management of medicines. Medicines were stored securely and access was restricted to authorised staff. Medicine room and refrigerator temperatures were monitored, and any temperatures outside the expected range were escalated to ward managers so appropriate action could be taken. The pharmacy team carried out regular checks on the safe and secure handling of medicines and provided wards with reports and actions to support improvement. However, on the labour ward, medicine storage arrangements were not sufficient for the volume of medicines being stored. Some medicines, including strips of tablets and ampoules, were not stored in their original containers. This increased the risk of staff selecting the wrong medicine and made it more difficult to identify and locate medicines safely. This was on service risk register, and the ward manager had applied for funding for this to be improved.

Emergency medicines and equipment arrangements did not always ensure critical medicines were immediately available in an emergency. Emergency medicines were not always immediately available for the treatment of postpartum haemorrhage (PPH), where prompt recognition and treatment were essential. On one ward, the PPH medicines box was empty despite records showing it had been checked and signed as available. Systems had not identified that essential emergency medicines were missing. Staff took immediate action to address the issue once it was brought to their attention. Otherwise, resuscitation medicines required in an emergency were available and reflected Resuscitation Council (UK) guidance. All emergency medicines were stored in tamper-evident emergency trolleys to help ensure they remained secure and ready for use. All oxygen cylinders we checked were stored safely and were within their expiry dates. Staff completed and documented daily checks of emergency medicines and equipment to provide assurance that items were present, in date and safe to use.

Controlled drugs (CDs) were generally managed safely, although storage practices were not always in line with best practice. CDs were stored safely and securely, with access restricted to authorised staff. Staff completed and documented daily CD checks, which were undertaken by 2 members of staff. Trust-wide audits of controlled drug storage, record keeping and destruction were carried out, and the results were shared with individual wards to identify areas for improvement and support safe practice.

However, on one ward we observed a patient's personal property had been stored within a controlled drugs cabinet. This was not in line with safe storage practices and increased the risk of unnecessary access to controlled drugs.

There was no clinical pharmacy service on maternity wards although staff told us they did have access to pharmacy advice if needed. A recent 3-month pilot (completed April 2026) looked at the benefits of having a pharmacist working within the team. The pilot demonstrated there were positive outcomes and improvements to prescribing and safe medicines optimisation. Staff feedback highlighted improved patient care and reduced delays in prescribing and discharge process. Maternity staff we spoke with were also positive about the benefits of having a ward-based pharmacy service. A business case was being put forward for a specialist women’s health pharmacist.

We found systems to monitor medicines management were not always effective in driving improvement. The service completed a monthly audit on medicines management. We reviewed the May 2026 audit, which showed generally good compliance. However, there was no associated action plan, and the audit lacked sufficient detail. Where errors were identified, there was no explanation of the discrepancies or information on what actions were being taken to address them and improve practice.

Staff assessed and managed VTE risks in line with national guidance. Staff completed venous thromboembolism (VTE) risk assessments, which help identify patients at risk of developing blood clots in their veins. Where appropriate, patients were prescribed thromboprophylaxis (medicines used to prevent blood clots) in line with best practice. All patients we checked had a documented VTE risk assessment. Where appropriate, patients had been prescribed prophylactic medicines to reduce the risk of VTE.

Systems and processes supported timely access to medicines for patients. There was a pharmacy-led medicine ordering and supply service that enabled medicines to be supplied directly to wards. Staff had access to medicines outside of normal pharmacy opening hours through an on-call pharmacy service. Pre-packed medicines, including analgesia and antibiotics, were available to support timely treatment and reduce delays for patients. These arrangements helped ensure patients could access medicines when they were needed.

Midwives were supported to supply and administer medicines in line with legal requirements and recognised practice. Midwives were able to supply and administer certain medicines without an individual prescription under specific legal exemptions within medicines legislation. This enabled them to provide timely treatment for conditions commonly encountered in maternity services. For example, midwives could supply and administer medicines for pain relief during induction of labour. These arrangements supported timely access to treatment and helped meet patients' needs without unnecessary delays.

There were effective systems and processes to identify, report, and learn from medicine incidents. Staff followed a process for reporting and managing medicines-related errors and incidents. Reported incidents and trends were reviewed to identify themes and opportunities for improvement. Staff we spoke with understood the actions they would take if a medicines incident occurred and were able to describe the reporting process.

Learning from medicines incidents was shared with staff through a range of communication channels, including staff bulletins, messages of the week and noticeboards. The pharmacy team also provided education and training sessions for midwives, including guidance on the importance of documenting reasons for medicines omissions. These arrangements supported a culture of learning and continuous improvement in medicines safety.

National patient safety alerts (NPSAs) were effectively communicated and acted upon to support the safe use of medicines. NPSAs were communicated to staff, and action was taken to address identified risks. For example, all staff we spoke with were aware of the NPSA – risk of oxytocin overdose during labour and childbirth, issued by NHS England in September 2024. Staff demonstrated an understanding of the actions required to meet the alert and described how practice had changed in response. Local guidance had been developed to support implementation of the alert. Staff told us they were following this guidance and were no longer preparing oxytocin infusions in advance at ward level. This helped reduce the risk of oxytocin overdose and supported the safe management of women during labour and childbirth.