Nottingham City 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 women and staff were safe and protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. We also checked women’s liberty was protected where this was in their best interests and in line with legislation.

At our last inspection we rated this key question requires improvement. At this assessment the rating remains the same. This meant women were not always protected from avoidable harm.

The service was in breach of legal regulations pertaining to safeguarding and staffing.

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.

Lessons were not always learnt to continually identify and embed good practice. However, staff listened to concerns about safety and investigated and reported safety events.

Staff knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with trust policy. Staff could describe what incidents were reportable and how to use the electronic reporting system. We reviewed information submitted to the learning from patient safety events (LFPSE) portal between October 2024 and April 2025 prior to our onsite inspection and found them to be reported correctly.

The service had no ‘never’ events on any wards.

The governance team reviewed incidents on a regular basis so they could identify potential immediate actions.

Managers investigated incidents thoroughly. They involved women and their families in these investigations. We reviewed 20 Perinatal Mortality Review Tool (PMRT) investigation reports. We found the service used evidence-based guidance in consistently documenting a woman’s ethnicity as part of this review to consider health inequalities. Staff also involved the views of women and their families.

Managers shared learning with their staff; however, this was not always effective. The service provided incident feedback through email, newsletter and a process called ‘10 at 10’ on the labour ward. However, not all staff could articulate any learning that had occurred following a recent incident. The Governance team said that they were looking into different ways in which they could communicate learning with the whole team. Staff reported safety incidents clearly and in line with trust policy.

Staff understood the duty of candour. They were open and transparent and gave women and families a full explanation if things went wrong. Governance reports included details of the involvement of woman and their families in investigations and monitoring of how duty of candour had been completed.

There was meaningful discussion and consensus if an incident required an after-action review or should progress to a patient safety incident investigation. The service had implemented a system of daily multidisciplinary triage to quality risk and safety so that cases could be discussed with obstetric and anaesthetic colleagues.

The trust had implemented a new risk management policy and process in September 2024. It had aligned its risk oversight process to this policy. Risks entered on to the risk register aligned to those articulated by the leadership team. The risk registered was reviewed monthly and scores amended as required.

The service monitored complaints made directly to the service and the trust patient advice and liaison service. Complaints were monitored through the Quality and Safety Oversight Group (QSOG) which met monthly. Data provided by the trust was not site specific but showed there were 6 open complaints within the electronic reporting system, which had been open between 11 and 664 days. Themes included standards of care and treatment, communication, and complications during of following birth.

Staff reported they were confident to report incidents, however, were not always assured action would be taken. Some staff we spoke with expressed a perception that, during incident investigations, a culture of assigning blame was present. They felt this was experienced more acutely by members of the medical workforce, particularly in relation to the approach taken by maternity and executive leadership.

We saw examples of where incidents had occurred, and practice had changed immediately to ensure women were protected from harm. However, staff felt the action taken was not always proportionate. For example, on one occasion, a reaction to an infusion led to a requirement for a midwife to provide continuous physical observation. However, this was not always feasible due to staffing constraints and activity.

The service worked with people and healthcare partners to 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 maternity advice line was open to pregnant women of any gestation until 6 weeks (42 days) postnatal. There was a clear escalation process and policy in place for telephone consultations. All consultations were documented on the woman’s individual electronic record which was visible to staff and enable recognition of women who called frequently.

The service had adopted the use of the Birmingham symptom specific obstetric triage system (BSOTS) which is an evidence-based risk prioritisation tool used in maternity services. At City Hospital maternity unit women from 20 weeks were able to be seen in maternity triage, however there was a caveat that women may be seen at an earlier gestation if they had complex medical or obstetric problems. There was comprehensive inclusion and exclusion criteria being used. For example, women in suspected labour were seen on the labour suite.

Evidence showed performance was consistently above the trust target of 90% for women being triaged within the prescribed 15 minutes of arrival. We requested site specific data however the service provided trust wide data as this is how it was collected and reported internally, therefore the data is mirrored with the Queens Medical Centre report. Between October 2024 and April 2025 between 93% and 95% of women were seen within 15 minutes of arrival. Following the initial assessment women were categorised for a medical review according to their presenting condition. For example, if a woman was categorised as orange, a medical review should take place within 15 minutes, yellow 1 hour, and green 4 hours. If a woman was categorised as red the emergency call should be put out for immediate review.

There was a formal process to review and monitor those women awaiting induction of labour. This was carried out on each site and then shared across both sites during the 9.30am safety huddle. Mutual aid was offered across both maternity services in Nottingham University Hospitals NHS Trust.

There were points throughout the day for the maternity team to come together for handover. Midwifery handover took place at 7am in each area of the maternity service. We observed a brief all-colleague handover to share overarching activity for the ward including safeguarding alerts. Once care was allocated midwives took 1:1 handover in a private space. We observed handovers followed the situation, background assessment and recommendation (SBAR) process. Following this the band 7 flow co-ordinator for the day visited each ward to obtain the “Bed State”.

Medical handover took place at 8:30am within the labour suite. It was attended by all members of the multidisciplinary team including obstetricians, anaesthetists, neonatologist and the labour ward and flow co-ordinator. The medical team discussed those women currently on the antenatal, labour, and postnatal wards, admissions for the day including planned caesarean sections and induction of labour. We observed good discussions regarding prioritisation of women awaiting and inductions of labour.

At 9.30am there was a cross-site safety briefing chaired by a matron. During this meeting there was a fixed agenda and discussion regarding the operation pressures escalation levels (OPEL) for each location and trust wide. We observed discussions and support being offered and mutual aid requested for women requiring induction of labour and planned caesarean section.

Training figures for safeguarding were low for some key staff groups, and information was not always shared quickly. Baby abductions drills were not always carried out there was a lack of security for newborns. However, the service worked well with people and healthcare partners to understand what being safe meant to them. 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.

Staff received training specific for their role on how to recognise and report abuse, but this was not meeting trust target levels for updating this training. We requested site specific data however the service provided trust wide data as this is how it was collected and reported internally, therefore the data is mirrored with the Queens Medical Centre report. Training records showed that as of May 2025, 66% of staff in this service had completed safeguarding level 3 training, this was further broken down to staff group which showed, 73% of midwives and 36% of medical staff. Data showed, that as of May 2025, 67% of staff had completed safeguarding adults level 2 training this was further broken down to show staff groups which showed 73% of midwives and 36% of medical staff.

There was a lack of system and process to check the identification bands of both mother and baby if they were separated, for example, the baby being taken by staff to the neonatal unit for intravenous antibiotics. However, there was a positive patient identification policy in place which did not specifically reference identification checks when babies are returned to their mother on the postnatal ward. We were told by staff and saw evidence of an incident where this occurred, and a baby was returned to the wrong mother.

We found continued breaches in relation to baby and infant abduction. Staff were unable to recall when the last baby abduction drill tool place, and some were unable to explain what they would do if they were alerted to an abduction. Babies born in Nottingham City Hospital were not security tagged which would provide an additional level of security. We found entry doors to wards closed very slowly, to comply with fire regulations, however, this was not known to all staff we spoke with. The inspection team observed people tailgating into secured areas, and staff opening doors to people without asking their identity. Ward staff were located too far from the entrance to be able to intercept people coming in or leaving. During our inspection the team challenged a visitor who was looking for a relative who was an inpatient on one of the medical wards.

Ward staff could give examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff understood the importance of supporting equality and diversity and ensuring care and treatment was provided in accordance with the Act. Staff gave examples which demonstrated their understanding and showed how they had considered the needs of women with protected characteristics.

There was a specialist team of safeguarding midwives based within the hospital who provided oversight and support of safeguarding to the maternity team.

There was a specialist provision for women who presented with female genital mutilation, including clinics within the community to improve access and attendance rates. The feedback from these clinics was positive and attendance rates and outcomes had improved.

Midwifery and obstetric staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff explained safeguarding procedures, how to make referrals and how to access advice, however there was minimal support on the wards for staff. The service had a safeguarding team who were based off site, and we heard accounts from staff where the safeguarding team were unable to attend to provide support. Care records contained where safeguarding concerns had been escalated in line with local procedures.

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.

Staff used a nationally recognised tool to identify women at risk of deterioration and escalated them appropriately. Staff used national tools such as the Modified Early Obstetric Warning Score (MEOWS) for women. We reviewed 10 MEOWS records and found staff correctly completed them and had escalated concerns to senior staff. The service monitored compliance with observation using its electronic system and based on the frequency of observations women were identified as being overdue. The trust target was set to reduce delays to 25%, maternity services were currently reporting above this at 33%. Work was underway to improve performance; a pilot was due to commence in July 2025 to implement a toolkit which had been introduced in other areas of the trust with positive outcomes.

The trust did not monitor the percentage of observations escalated appropriately in line with the MEOWS policy. However, an audit was in progress to identify if observations were repeated in line with guidance, and work was being planned to review if escalations were carried out appropriately.

Staff knew about and dealt with any specific risk issues. Staff reviewed care records from antenatal services for any individual risks. For example, staff used the fresh eyes approach to carry out fetal monitoring safely and effectively. Leaders audited how effectively staff monitored women during labour having continuous cardiotocograph (CTG). We requested site specific data however the service provided trust wide data as this is how it was collected and reported internally, therefore the data is mirrored with the Queens Medical Centre report. Data showed a clear trend of continuous improvement from 72% in July 2024 to 95% in February 2025. By February 2025 this was above (better than) the local maternity and neonatal system average of 80%. The service was in the process of strengthening its CTG audits by incorporating a dedicated section which focused on pathological CTGs and escalation decisions/action, which would then support improvements in intrapartum care.

The service did not routinely monitor caesarean sections and the timeliness of decision to incision for the differing categories of caesarean sections. However, this was reviewed as part of a case review learning response and delays from decision to incision was not highlighted as a concern. Additionally, we observed the maternity team acting swiftly in emergent situations including achieving the target for a category 1 caesarean section (decision to incision should be within 30 minutes).

The service had 24-hour access to mental health liaison and specialist mental health support. Staff explained when and how they could seek assistance to support women with mental health concerns. Staff completed, or arranged, psychosocial assessments and risk assessments for women thought to be at risk of self-harm or suicide.

There was a process to support women who chose to give birth outside of national guidance. This was especially common to those women requesting a homebirth who were identified as high risk. We heard women were choosing to birth at home due to fear generated by the negative publicity from the independent maternity review. The homebirth team had consultant oversight and would meet with women and develop a mutually agreed plan of care.

Staff shared key information to keep women safe when handing over their care to others. The care record was on a secure electronic care record system used by all staff involved in the woman’s care. Each episode of care was recorded by health professionals and was used to share information between care givers.

Shift changes and handovers included all necessary key information to keep women and their babies safe. During the inspection we attended staff handovers and found all the key information needed to keep women and their babies safe was shared. Staff used handheld electronic devices, which had up-to-date information for each woman who was an inpatient on the ward. The handover shared information using a format which described the situation, background, assessment, recommendation for each person.

Staff completed newborn risk assessments when babies were born using recognised tools and reviewed this regularly.

The service did not have a transitional care service for babies who required additional care; however, staff were in the process of developing a transitional care provision. As part of the avoiding term admissions into neonatal units (ATAIN) the service monitored the unplanned admissions to the neonatal units. We requested site specific data however the service provided trust wide data as this is how it was collected and reported internally, therefore the data is mirrored with the Queen’s Medical Centre report. Evidence provided showed, between September 2024 and March 2025 the numbers of babies admitted to the neonatal unit ranged between 3% and 5.8%, which was consistently below (better than) the target of 6%.

Staff completed risk assessments prior to discharging women into the community and made sure third-party organisations were informed of the discharge.

Leaders monitored waiting times and made sure women could access emergency services when needed and received treatment within agreed timeframes and national targets.

The service did not always detect and control potential risks in the care environment. However, staff made sure equipment, facilities and technology supported the delivery of safe care.

The service had undertaken a ligature risk assessment following the NaTPSA/2020/001/NHSPS safety alert. The service had ligature cutters available; however not all staff knew where they were kept.

We saw call bells were accessible to women if they needed support and staff responded quickly when called.

Portable gases including Oxygen and nitrous oxide (N20+02) were stored securely and in line with national guidance.

The design of the environment followed national guidance. The maternity unit was fully secure with a monitored entry and exit system. However, we noted door closures were delayed. Staff told us they had escalated this but no action had been taken.

Staff carried out checks of emergency trolleys each day and checklists and records were maintained electronically. In addition, staff also used paper records to confirm the checks had taken place. However, the paper records were incomplete and did not provide assurance the trolleys had been checked as required.

Resuscitaires were available on the labour ward and in the birthing centre. However, the resuscitaire in the birthing centre was not easily accessible as it was stored behind other items of equipment in a store cupboard.

The service had suitable facilities to meet the needs of women and their families. The birth partners of women were supported to attend the birth and provide support.

The service had enough suitable equipment to help safely care for women and babies. For example, in the birth centre there were pool evacuation nets in all rooms and on the day assessment unit there was a portable ultrasound scanner, cardiotocograph (CTG) machines, and observation monitoring equipment. There were enough CTG machines, to monitor women and their babies and on the antenatal ward they were equipped with Dawes Redman capacity (a computerised method designed to analyse antenatal fetal heart traces). However, there was no centralised CTG monitoring on the labour ward in line with national recommendations.

The community midwives had access to the equipment they needed to carry out their role. However staff were not assured risk assessments had been undertaken for carrying medical gasses in their cars.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins. They stored waste in locked bins while waiting for removal.

Following on from a coroner's inquest where a prevention of future deaths (regulation 28) report was issued, the process of storing placentas was changed for the cases where babies were born and transferred to the neonatal unit but then subsequently died. the service developed a process to keep all placentas on labour ward for 72 hours following birth in case they were required for histology. This was not a national requirement for all maternity units and appeared to be unique to Nottingham University Hospitals Trust resulting from the historical failings in care.

There was a midwifery led unit with 4 rooms which were decorated as though they were a home from home. There were birthing pools which were in accordance with best practice guidance (accessible from 3 sides). Nets were also available in the event of a woman requiring emergency evacuation from the birthing pool. However, we found and were told the rooms were underutilised. Staff regularly checked birthing pool cleanliness, and the service had an effective system for legionella testing of the water supply.

The service did not always make sure there were enough qualified, skilled, and experienced staff. The service did not always make sure staff received effective support, supervision, and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff completed study days for additional mandatory training relevant to their role including maternity update days, maternity obstetric drills, and fetal wellbeing days. The training was attended by obstetricians, anaesthetists, midwives, and maternity support workers. The maternity obstetric drills study day covered a wide range of obstetric emergencies such as post-partum haemorrhage, impacted fetal head breech births and third- and fourth-degree tears.

We requested site specific data however the service provided trust wide data as this is how it was collected and reported internally, therefore the data is mirrored with the Queen’s Medical Centre report. Data showed between November 2024 and May 2025, between 79% and 92% of midwives had completed practical, obstetric, multi-professional training (PROMPT). However, this was not always above the trust target of 90%. Medical staff compliance with PROMPT training November 2024 and April 2025 showed

• between 92% and 100% of consultants
• between 86% and 100% of resident doctors in post before July 2024,
• between 65% and 90% of resident doctors in post after July 2024 had completed training.

Data showed between November 2024 and May 2025 between 91% and 95% of midwives had undertaken fetal monitoring training. Data from January 2025 to April 2025 showed

• between 83% and 97% of consultants
• 91% and 98% of resident doctors had completed fetal monitoring training. This was above (better than) the trust target.

The service had a team of trained professional midwifery advocates (PMAs) to support professional development and supervisions. They provided support Monday to Friday and took part in the manager on call rota.

There was a team of preceptorship and retention midwives which included legacy midwives to support newly qualified midwives and midwives new to the trust during their preceptorship period.

The service had a practice development midwife and a multi-professional educational team. Comprehensive educational sessions were planned in a structured schedule and staff confirmed training was rarely cancelled.

The newly qualified and internationally educated midwives all reported the training and preceptorship support they received was very good. However, they did not always receive adequate supernumerary time before they started clinical work. Supernumerary status was important for newly registered midwives to ensure they had dedicated time for learning and practice in accordance with evidence-based practice guidance and trust policy.

The service conducted spontaneous skills and drills of obstetric emergencies, however, these were mainly focused within the labour suite. Staff had recognised there was a lack of spontaneous skills and drills on the antenatal and postnatal wards. This was a gap in emergency preparedness on the antenatal and postnatal wards.

The service reported safe staffing continued to be a priority on both a strategic and daily basis. The last full midwifery staffing and acuity assessment was carried out in November 2022, which was within the triannual expectation.

There was a supernumerary flow co-ordinator on duty around the clock who had oversight of the staffing, acuity, and capacity and a supernumerary labour suite coordinator. We observed them working effectively to help the flow of patients.

The service reported maternity ‘red flag’ staffing incidents in line with National Institute for Health and Care Excellence (NICE) guideline 4 ‘Safe midwifery staffing for maternity settings. A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing. The service input data into the birthrate+ App 6 times in each 24-hour period to accurately map and track staffing across the service. For example, data recorded in February 2025 for labour suite showed 1% of the time was more than 3 midwives short, 21% where there were up to 3 midwives short, 78% staffing met acuity. Data input compliance was 95% of the time.

Managers accurately calculated and reviewed the number and grade of midwives, midwifery assistants and healthcare assistants needed for each shift in accordance with national guidance. The maternity workforce was discussed in detail at trust board. The midwifery workforce vacancy rate had reduced significantly from August 2024 to May 2025. Reports showed there were 28 whole time equivalent band 5 and 6 midwifery posts in the process of being recruited and leading to the service being over recruited.

The site flow co-ordinator was able to discuss and move staff according to the need within each clinical area. Although staff reported they were not happy about moving clinical areas, they understood the rationale and accepted the need to protect the safety of women.

Managers requested bank and agency staff familiar with the service and made sure all bank and agency staff had a full induction and understood the service.

The service had a comprehensive network of specialist midwifery roles including:

• Public health
• Maternal medicine
• Multiple pregnancy
• Infant feeding
• Training and development
• Intrapartum matrons
• Consultant midwives

There were also externally funded specialist midwifery roles which included international recruitment, student practice development and clinical educator, trauma informed midwife, recruitment and retention, engagement and inclusion, and legacy mentors.

The service supported staff to be competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Appraisal rates were improving. We requested site specific data however the service provided trust wide data as this is how it was collected and reported internally, therefore the data is mirrored with the Queen’s Medical Centre report. Between October 2024 and April 2025, appraisal rates improved from 75% to 84%. There was a plan to recover this position to the trust target of 90% which included advanced appraisal date booking.

There was a homebirth team which formally commenced in March 2024 and facilitated 110 homebirths in the first year. The service was available 24 hours a day 7 days a week and was staffed by 2 midwives on a long day, another midwife working 9am to 5pm, and 2 midwives overnight. The homebirth midwives were based in Nottingham City Hospital overnight; however, they did not support clinically on the wards at times of escalation process. This meant there were 2 qualified midwives based in Hospital overnight who were not supporting the delivery of care.

The service did not have enough medical staff with the right qualifications, skills, training, and experience to keep women safe. There were gaps in the medical rota, which included a long-term gap of 1 consultant (due to sickness and modified duties) 0.8 Senior specialist trainees +0.2 Junior registrar (1 whole time equivalent not doing on call) and 0.6 foundation year 2 doctors. We also found 20% of consultants in post were on limited duties, however, rota gaps were covered internally which was placing additional strain on other consultants.

In addition, the post of obstetric clinical director was vacant and presented a significant risk to the service although there was a plan to rectify the position.

The number of programmed activities for the medical team fell short of safe levels. Evidence showed the required number of programmed activities (PAs) for the medical team was estimated at 142.1. However, it was noted this needed to be revised because of increasing demand in the antenatal clinic and the elective caesarean section list. The number of PAs provided at the time of the inspection was 134.85, which was not adjusted to account for 2 consultants on planned leave. This meant there was a gap of 7.25 PAs which equated to a minimum of 29 consultant hours.

There were 10 anaesthetic consultants which covered the maternity service on call rota. This consisted of 1 day cover for emergencies every 2 weeks.

There was a maternal medicine team which supported women with complex pregnancies. We observed the multidisciplinary team working together to support pregnant women who presented with complex medical needs. Comprehensive plans were developed and discussed with women during their antenatal care. There was continued oversight and support if women were admitted as emergency inpatients.

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.

Maternity service areas were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning records were up to date and demonstrated all areas were cleaned regularly.

The service generally performed well for cleanliness; there were effective plans to ensure curtains were replaced appropriately. For example, disposable curtains were replaced every 6 months and cloth curtains replaced every 3 months.

Staff followed infection control principles including the use of personal protective equipment. We observed staff maintained basic infection prevention and control practices including, handwashing, being dressed bare below the elbow in accordance with uniform policy, and wearing the required uniforms.

Leaders completed regular infection prevention and control and hygiene audits. Data showed hand hygiene audits were completed every month in all maternity areas.

The service monitored the prevalence of women who were readmitted with puerperal sepsis. Data provided showed between October 2024 and January 2025 this ranged between 0.3% and 2.5% of deliveries. This was in line with the national average.

Staff cleaned equipment after contact with women and birthing people. Staff cleaned couches between use in the antenatal clinic, and it was made clear equipment was clean and ready for use using I am clean stickers.

The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences. Staff involved women in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. The service used an electronic prescribing system for medicines that needed to be administered during their admission. We reviewed 10 prescriptions and found staff had correctly completed them.

A maternity pharmacist supported wards Monday to Friday 9am to 5pm. Staff administered medicines safely to women on the maternity wards. Medicines were stored safely and securely and the ambient temperature of all clean utilities. Prescription pads (FPP10) were stored safely. Checks ensured prescriptions could be tracked once issued.

Patient group directions were stored electronically. Daily checks on fridge temperatures were completed in line with policy.

The homebirth team did not use any opioid medicines for homebirths but carried Nitrous Oxide in their cars. However, leaders were unable to confirm if the appropriate risk assessments and signage were in place.

We also saw women who met the criteria for venous thromboembolism prophylaxis and were also requesting a homebirth had their treatment prescribed and were able to continue following their planned birth.