Maternity services rated 'unsafe' by inspectors

Life-threatening bleeds continue to rise at a maternity unit that requires "immediate improvements", inspectors have said.

A mother, who is also an Afghan doctor, says she had better pain relief giving birth in Afghanistan than for a planned C-section at Gloucestershire Royal Hospital last July.

A delayed Care Quality Commission (CQC) report from an inspection in March 2024, but only published this week, found maternity services were still deemed to be unsafe.

The trust said it had made "significant improvements" but accepted there was more to be done.

The Afghan doctor, who did not want to be identified due to her links with the British military, said she has been left with lingering health complications following the birth.

She said her experience was "traumatic" as there were inadequate translation services and she was given insufficient pain killers.

Her husband also complained that he was treated poorly and was shouted at by medical staff.

He said it was only after he contacted the BBC that the situation began to improve.

The health trust that runs the hospital said it introduced new translation services in September 2024.

The incident follows an unannounced inspection by the CQC to the Gloucestershire Royal Hospital last spring, which resulted in a warning notice being issued to the trust.

In May, the CQC imposed urgent conditions requiring the trust to address critical concerns about the safety of care provided to women and service users, as well as how the service is managed and led.

Nearly eight months later, in January 2025, those conditions remain in place.

The trust is now required to provide fortnightly updates to the CQC on the progress of its action plan to address the issues raised.

Despite ongoing efforts, maternity services at the hospital have been rated "inadequate" overall, with specific concerns noted in the areas of safety and leadership.

Catherine Campbell, CQC's head of hospital inspection, said the measures were necessary to ensure the trust prioritises the safety of patients while addressing longstanding systemic issues.

Further inspections may follow to assess progress.

"Our inspection of maternity services at Gloucestershire Royal Hospital revealed that while we saw some positive changes, not enough work had been done yet to address the basic issues around safety," Ms Campbell said.

"We were still concerned about how the trust managed systems to identify risks to mothers, babies and people using the service. Some people told us they didn't always feel safe in the department."

She added that leaders did not properly induct agency staff or provide access to essential systems, causing care delays.

"For example, agency midwives didn't always have security door fobs and would need to rely on other staff during emergencies, creating potential risks to people's safety due to those delays.

"It was a concern that staff felt there wasn't a proactive safety culture. While some felt they hadn't been supported after raising concerns and were reluctant to do so again as a result," she added.

Inspectors found that a life-threatening bleeds were continuing to rise and there were delays in escalating deteriorating patient conditions.

However, the report says the trust had improved staffing numbers and ensured staff completed mandatory training.

New midwives and those who were internationally recruited were receiving extra support from practice development midwives.

Inspectors saw also examples of translation services to support people whose first language was not English.

Recruitment processes were thorough and safeguarded people who use the service from harm or abuse, they said.

Safety Champions for maternity had started a programme of attending all areas of the maternity service.

This was to work alongside and engage with staff to gather their views and create a more open culture, the report said.

Kevin McNamara, chief executive of Gloucestershire Hospitals NHS Foundation Trust, said the trust had made "significant progress" since the inspection last year, but added it recognised "there's more to do".

"We acted immediately in response to the feedback from inspectors and the CQC has been closely involved with us in driving these improvements throughout," he said.

"They have recognised the progress that has been made and I want to reassure families that we are committed to providing high-quality, safe maternity care."

Chief nurse Matt Holdaway added: "It is important for expectant parents and those families accessing our services to hear about the good care we continue to deliver.

"In that regard we are continuing to invest heavily in our service, to work closely with regulators and advisory teams, to ensure that we can continue to provide a service that we are all proud of."

Mr Holdaway added that as of September 2024, a new translation service has been appointed for Gloucestershire, providing more than 350 languages and dialects.

The service is accessible 24/7 and has already been used on more than 2,600 occasions, including 650 times in the maternity unit.

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