Royal Derby Hospital

On this page

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

We looked for evidence that women and communities had the best possible outcomes because their needs were assessed. We checked that women’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring women were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This key question was not rated at our last assessment but was previously rated as Requires Improvement. At this assessment the rating remained requires improvement.

We have not awarded this service a score for Effective.

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

The service did not make sure women’s care and treatment was effective. Evidence showed staff incorrectly interpreted CTG’s, failed to recognise risk, did not escalate appropriately delayed escalating concerns, and delays in medical reviews being completed. During our inspection we saw observed an instance, when a fetal heart trace deteriorated, and staff failed to act. We also saw evidence which demonstrated CTGs were not always interpreted or acted on in accordance with national guidance putting women at risk.

We also observed, women did not always have appropriate risk assessments which included venous thromboembolism and postpartum haemorrhage in place. We also observed some women waiting to be seen on the triage unit had not been risk assessed.

We observed the service was not following their policy and process on IOL in relation to managing those women who were unable to start or continue the process due to staffing concerns. We saw evidence where a higher risk, IOL was not prioritised placing the baby at risk of harm.

Midwives in the antenatal ward told us consultants cancelled caesarean sections without assessing the individual person needs and potentially placing the person at increased risk of harm, however, we were unable to corroborate this information as there was no reports on the learning from patient safety events (LFPSE) portal.

The service did not always plan and deliver women’s care and treatment with them, including what was important and mattered to them.

Staff had assessed the women’s needs but then failed to act on them. During the assessment we saw there were high risk women who met the criteria to be prioritised for induction of labour. However lower risk women were prioritised over them. Therefore, we concerned about the risk assessment and prioritisation process for induction of labour was effective.

We reviewed the services policies and found that they were written in line with NICE and RCOG guidance. These were reviewed within in a specific timeframe or when national guidance changed.

Staff, teams and services did not work together to support birthing women and mothers. The labour ward coordinator did not have a “helicopter” view of the maternity service. The flow coordinator did have a better understanding of the overall service; however, it was not clear how the ward and flow coordinators worked together. Additionally, managers did not have effective processes in place to relay information to each other.

The sharing of information was poor, the handover process was in accordance with the trust handover guidelines, however this lacked privacy and dignity for women who had just given birth. Following an overview of the ward to every member of staff in depth handover was carried out at each bedside. We observed this process and was able to hear the full handover for each patient in that bay. Staff reported they felt handovers were ineffective, however, they were not able to deviate from this trust wide process.

Staff did not work together well to provide safe care that met women’s individual needs. During our onsite assessment we witnessed only one anaesthetist that was visible on the wards and was present at handovers. Other clinicians such as obstetricians were not visible on the ward and did not routinely attend handovers. whilst we were on site. At the last inspection required by the commission in August 2023, we asked the trust to take immediate action to provide adequate senior midwife clinical support from midwifery leaders' band 8a and above at the Royal Derby Hospital. The trust had complied with this.

The service did not always support women to manage their health and wellbeing to fully maximise their independence, choice and control. The service did not always support women to live healthier lives and where possible, reduce their future needs for care and support. Evidence reviewed showed that not all women were given smoking cessation advice, referrals to smoking cessation services and not all were appropriately screened for gestational diabetes and fetal growth restricted babies.

We did find the service had implemented a project in order to improve women’s understanding of smoking whilst pregnant. Data from NHS England shows the percentage of mothers smoking whilst pregnant has declined which had improved from the previous inspection however not all women were involved in this.

Evidence showed that 13% (n657) women at booking had a body mass index over 35. We were unable to identify what if any support this cohort of women received during their pregnancy to maximise their health and reduce the risk of complication.

The service did not always monitor and manage the care and treatment the service provides to learn lessons and improve outcomes.

We found that staff went above and beyond operationally, however the outcomes for women, birthing women and babies were not always positive and consistent. The service had a quality dashboard which was broken down by site but also shows the overall trust maternity performance.

The service had also not done what was reasonably practicable to reduce the risk of post-partem haemorrhage (PPH). This was a requirement from the previous inspection. Staff felt there had been a lack of leadership engagement in reducing PPH and potential major obstetric haemorrhage (MOH) since our last inspection

We found that from April to November 2024 evidence showed the rates of post-partum haemorrhage (PPH) over 500mls ranged between 40% and 45% of all births, we also saw, during the same time frame of those PPH between 49% and 37% were identified as major obstetric haemorrhage (MOH) which is defined as a blood loss over 1000mls placed women at risk. A PPH is where a mother loses 500mls or more of blood and a MOH a mother loses 1000mls or more of blood. This posed a significant risk to women.

Staff told us that PPH and MOH rates were improving, and they were more aware of them, but they also knew that their rates remained high. In addition, staff reported a lack of training for PPH and MOH as it no longer formed part of Practical Obstetric Multi Professional Training (PROMPT).

Since our previous inspection the service had implemented emergency pool evacuation. Evidence provided showed as of December 2024 74% of labour ward and birth centre staff have current training for pool evacuation, however overall compliance of among midwives was 54%. There was a plan in place to ensure the serviced met the 90% target of training compliance.

Evidence showed between April and November 2024 there were 25 women admitted to the intensive care unit. Staff were unable to articulate what if any analysis had been done to reduce this number. However, during the factual accuracy process the service provided data which showed there had been a 42% reduction in admissions to ITU resulting from the inclusion of nurses working within the enhanced maternity unit.

Evidence showed between April and November 2024 there were 51 babies born before arrival of a midwife (BBA). Staff were unable to articulate what if any analysis had been done to reduce this number.

We also saw evidence which showed the numbers of vaginal births after caesarean section (VBAC) were low. Between April and November 2024 only 2% (n82) women had successful VBACs. This is significant worse than the national average. However, we were unable to identify any programme or process to support women to have a successful VBAC.

Staff told us that they had ongoing concerns re clinical outcomes and expectations especially with the skill mix of staff working within the maternity service.

Staff would arrange for women to be reviewed at home via the Community midwifery team.

The service did not always provide women with all the information they needed to make an informed decision about their care.

Leaders reported some staff lacked confidence in the consent process especially during the induction of labour process. Additionally, they reported some staff lacked confidence to challenge medical decisions. We were not made aware of any mitigations such as training or professional midwifery advocate support to improve staff confidence.

Women were not given sufficient information on the risks of delaying the induction of labour process at full term, such as increased likelihood caesarean and still births. Therefore, women were not making fully informed consent.

We found women were not given. We also saw IOL risk assessments were not always being completed, and inappropriate decisions were made for example a low-risk IOL was prioritised over a high-risk IOL.

Staff told us when asking for consent they would discuss with the woman, what they would do, if emergency consent wasn’t given. They would then find a middle ground to respect the woman’s wishes and also ensure safe treatment for both mum and baby. We were not made aware of a formal process when a woman chooses to give birth outside of guidance. We found discussions were not always evidence based or aligned to national guidance which was a risk to women and their baby.