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Maternity risks at Torbay and South Devon NHS Foundation Trust

By Jack Fox

Published In: Clinical Negligence

The Care Quality Commission (CQC) has rated the safety and leadership of maternity services at Torbay Hospital in Devon, part of Torbay and South Devon NHS Foundation Trust, as ‘requires improvement’ following a short notice inspection as part of its national maternity inspection programme in November 2023.

mother and baby hands

Some of the key findings are as follows:

  • The health regulator found that a shortage of experienced doctors in its maternity service was exposing mothers and babies to a risk of avoidable harm. The Trust had completed a full review and had identified the need for four additional (obstetric) consultant posts. This was being considered.
  • Given the lack of experienced doctors, there was a limited time for consultants to attend training, provide teaching and support to junior doctors and for rest following ‘on call’ shifts. There was also not enough time for those doctors to review and update guidelines and policies. 7 out of 10 obstetric consultants were overdue an appraisal of their performance.
  • The inspection identified how the leadership team did not always manage the maternity service priorities for ensuring the best outcomes in a timely way for women, birthing people and babies. Some staff told the regulator they did not feel maternity services were a priority for the trust board and did not implement changes to manage identified risk, quickly enough. Some staff said the issues they raised were not always taken seriously.
  • There was no second on-site emergency theatre team or allocated theatre for out of hours emergency obstetric surgery. This created a risk of delay in women and birthing people getting emergency surgery within the required timescales.
  • The hospital did not have enough suitable equipment to help them to safely care for women and birthing people and babies such as resuscitaires (equipment which combines a warming therapy platform along with the additional equipment required for managing neonatal clinical emergencies and resuscitation), and CTG machines (CTG continuous cardiotocograph to monitor the babies heart rate). In particular, the CTG machines were old and frequently required maintenance.

 Carolyn Jenkinson, CQC’s deputy director of secondary and specialist care, stated:

 “Executive leaders lacked urgency to support the service to address issues when they were found, and this was putting people at risk of harm.

 The trust board weren’t always taking enough action to address or manage risks when they were identified. Although leaders acted quickly to address risks we highlighted at the inspection, action could have been taken sooner as they were already aware of them. This included concerns regarding the need for a second theatre to carry out emergency surgery and staffing levels.

 We also found poor systems and processes for assessing women and people using the service who needed medical attention, including no dedicated triage phone line. People could call a general phone number if they had any health concerns, but it could have been answered by staff without the right training to assess their needs. Staff also weren’t using a standard method to assess and prioritise people based on clinical need. However, leaders made improvements to this following our feedback.

 There wasn’t always enough equipment to support the number of women, people and babies using the service. This included machines that can help babies in emergencies and with resuscitation, and equipment which monitors babies’ heart rates. Staff shouldn’t have had to share important equipment around, and we were pleased the trust planned to address this.

 Despite these concerns, we found staff and leaders were committed to improving the service. They engaged with the local community and sought feedback by hosting group sessions, baby cafés, and visiting children’s centres. They had several ongoing improvement projects including work to reduce smoking in pregnancy. They were also working to reduce health inequalities for people using the service who experienced social deprivation, which included a free phone line giving advice to people experiencing financial difficulties.

 We will continue to monitor the trust, including through future inspections, to check on the progress of the improvements we’ve told them to make, to ensure people and their babies receive a good standard of care.”

If you have been negatively impacted by treatment provided by Torbay and South Devon NHS Foundation Trust or any other healthcare provider in England and Wales, please get in touch so that we can start to help you. Call us on 0800 138 0458 or email and we'll get back to you.

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Jack qualified as a Solicitor in 2019. He’s a member of our Medical Negligence team.


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