Independent Review into Maternity Services at the Trust

Dear Donna

Thank you once again for your letter, dated 18 December 2024, and for the feedback it contains about the issues, concerns and positive feedback that have been discussed and shared with you and your team. I remain grateful to you for providing regular and feedback to support our ongoing perinatal improvement journey. I want to acknowledge the concerns that have been expressed by both women and their families, as well as current or former colleagues who work in our perinatal services. 

It is important that we address the feedback you have received and please accept my assurance that we will continue to include your observations and recommendations in our programme of improvement. I will respond to the issues you have raised in the order they were presented in your letter. 

1.     Overdue escalations requiring progress for individuals

I apologise for the delay in providing responses to you, and for the escalations for which you have not yet received an update. In this letter, I have included a summary of the updates and will ensure these are provided to you. There is a new process in place for the Trust to provide updates to you, and I hope that this new system ensures that we can provide regular and timely updates to you in relation to your escalations.

• The Trust has commissioned an independent external review of the concerns raised by Mrs Anonymous 1 and her family in August 2024. A letter from the Chief Nurse seeking consent from the family to share the records with the independent reviewers has been drafted and will be sent once you confirm it is acceptable for the Trust to contact the family direct.
• The review of the interpreting services is an ongoing programme of work and the Linguistics Working Group is due to report shortly. We will monitor progress via our Trust contacts process and provide you with a copy of the report once it has been completed.
• The temporary member of staff referred to by Mrs J has not worked for the Trust since December 2023 and the Trust no longer uses the agency for which she worked.  The Director of Midwifery has confirmed that the agency was made aware of the concerns with the Midwife at the time that these were raised to us.
• Mrs L’s case was managed as an “out of time” concern response. The response, along with the Serious Incident investigation report (July 2018), was sent via the supplementary request process on 18 December 2024. 
• Mrs Anonymous 2’s case was managed as an “out of time” concern response. The response, along with the Serious Incident investigation report (July 2018), was sent via the supplementary request process on 18 December 2024. The final report of the Trust-commissioned external review into the case has been shared with the family and the Trust. Our response is being developed and the report and action plan are being shared internally and externally. An apology letter has been sent to the family from the Chief Nurse. A copy of the report was shared with the family in January 2025. The Trust’s response will be shared with you when it is finalised.
• The complaint response in relation to Mrs Anonymous 3 is nearing completion. I would like to apologise for the delay.
• I understand your concerns in relation to the theme that ‘clinical documentation does not in some case reflect the experiences or lived experiences of families’. This is a complex area, and the Trust is considering several programmes of work to ensure that it can respond effectively to the concerns raised and ensure that clinical records and documentation accurately reflects the lived experience of families. For example, we have worked hard to ensure that handovers are recorded more fully.
• The internal review of the care of Mrs O has been completed and was shared with your team on 18 December 2024 via the supplementary request process. You asked whether the Trust could provide an appointment for Mrs O. We understand that Mrs O has previously opted to access services elsewhere, but we would be happy to arrange an appointment with an NUH gynaecologist if Mrs O would like that.
• We have shared the feedback on the anonymous concern with the Director of Midwifery. Without more specific information we are unable to investigate this case further. If further information is available, we can, of course investigate this as a matter of urgency.
• The Director of Midwifery has confirmed that several steps have been taken to ensure staff are aware of the long-term effects that their behaviour can have on new parents. This includes a session at the start of every Practical Obstetric Multi Professional Training (PROMPT) course on culture and impact of behaviour on team and patient experience, as well as development programmes with teams on culture. 
• Following an initial review, the Medical Director has commissioned a review of Mrs Anonymous 7’s case. 

2.     Concern with early pregnancy care and pregnancy loss - A23 ward at QMC

I would like to apologise to the women and their families for the experiences that you have described.  This is not acceptable. Where specific examples are raised with the Trust, we will continue to address these. 

I recognise that the physical infrastructure requires some modernisation and improvement.  We have started to develop plans to address this.  A meeting was held in November to discuss the provision of a dedicated early pregnancy unit at NUH. The Clinical Lead and the Assistant General Manager for Gynaecology are leading on the development of a business case to progress this. Clearly this has to be set in our current financial circumstances.

Alongside the development of the physical environment, we have committed to modernising and developing the patient pathway. One aspect of this is to ensure we are caring for patients in the most appropriate setting. This has commenced with the introduction of the push model out of the Emergency Department (ED) for all specialities. This ensures that any patient identified with a gynaecological problem is transferred and assessed on Gynaecology Triage Unit (GTU) rather than waiting in ED. To support the push model, regular interface meetings take place between the clinical teams. This ensures regular and effective communication of any issues so they can be addressed as early as possible. 

I am conscious of the challenges faced in terms of scanning. The service is currently reviewing the criteria for scanning patients and developing a Standard Operating Procedure to support improvement. Colleagues are focussed on the support required for families when receiving bad news. Two side rooms have been allocated and will be improved to create an appropriate environment. This work has been supported through the Forever Stars charity. I recognise that there is no quiet room available on A23 for breaking bad news and I have asked colleagues to explore options to resolve this. A new bereavement nurse for pregnancy loss took up post in January 2025.

You have raised several important issues in relation to effective resources, particularly in relation to both medical and nurse staffing and the leadership of the service. Ensuring we have an effective service model and staffing structure is a key priority. A safer staffing review of nursing was undertaken in September 2024.  This identified gaps in our establishment, particularly in respect of service delivery and leadership. This has now been addressed with additional leadership roles present on every shift and increased registered nurses at night to support with the provision of one-to-one care to women experiencing second trimester pregnancy loss. 

As part of this process additional miscarriage care training is being provided to staff on the ward. We have prioritised recruitment and retention in the service, and I am pleased to report that there are now minimal vacancies on the ward. We have staff who aspire to take on deputy sister roles, and NHSP staff who would like permanent posts. Management support for the service has been strengthened with a new experienced interim Ward Manager for GTU. The substantive post will commence in March, and a full induction plan with peer support has been arranged.

In relation to the concerns raised regarding medical cover on GTU, I recognise that our medical workforce and structure requires further development. The structure for medical leadership within Emergency Gynaecology has a Clinical Service Lead, a Head of Service for Emergency Gynaecology, and a Clinical Director for Reproductive Health. These posts work in a triumvirate model with nursing and managerial colleagues and are responsible for the strategic leadership of the service.

On a day-to-day basis, medical leadership is provided by the Consultant Gynaecologist and the Gynaecology Registrars.I recognise that junior doctors within Emergency Gynaecology have previously reported that they have not had consistent support from senior colleagues. As a result of this, from August 2024, an additional dedicated Registrar dedicated to Emergency Gynaecology has been added to the rota. This additional cover is in place 24 hours a day, seven days a week (ST4 or above). Feedback from colleagues about the presence of an additional dedicated registrar has been positive. The registrars who are on the rota are reporting that it provides valuable learning and development opportunities for them. 

Previously, I described how we have increased our resident consultant time by two hours every evening, and I can confirm that this remains in place. We have changed our rostering for the on-call consultants. Rather than doing a hot week, where they are on call, there is now a split week. This was done to reduce decision fatigue and to support medical colleagues. In addition, there is always a second on-call gynaecology consultant at the City Hospital site available to support at QMC, as required. 

There is a continual focus on listening and responding to staff concerns and ensuring regular communication and meetings with staff. This is supported by our Freedom To Speak Up Guardians who have provided a strong presence in, and support to, the service. The ward has introduced an anonymous box for staff to raise concerns or compliments, and to share details of what is going well. Listening sessions with the matron, ward leader and divisional nursing team are being arranged. 

You raised concern that women at 16+ weeks of gestation are treated differently from those at 20+ weeks, depending on whether they are booked for maternity care at City or QMC. As you describe, this can lead to a discrepancy in care. We have an extensive programme of work in the Trust under the maternity and neonatal improvement plan, which expands neonatal services at the QMC campus. Now that the new neonatal unit has been opened, we are working on the pathways of care across the organisation. As part of this programme of work we are looking to harmonise and strengthen treatment pathways. 

I have provided a detailed overview of ongoing work on A23 and in terms of the Emergency Gynaecology service. I recognise that there is still much to be done in terms of the infrastructure, staffing and the culture of the service, but all are integral to a combined improvement programme to which we are fully committed.

3.     Postnatal care

Thank you for raising concerns in relation to post-natal care and the issues raised by colleagues working in the community. I will provide some details of the improvements we have made in relation to our community midwifery services. 

Over the past year we have undertaken a full review of our community midwifery services, as we recognise the need to improve and strengthen these. As the population across Nottingham and Nottinghamshire has changed, it is essential that our services adapt and develop. This review is nearing completion. Once completed we will share the findings and proposed service models with you. In the meantime, we have strengthened our pathways of care. For example, all women have a face-to-face visit at home on transfer from the hospital. Women receive a phone call, with a focus on feeding, and a face-to-face visit with either a midwife or a maternity support worker at day five. 

All women have a “safe and well” phone call around day 10 to discuss any concerns or support needs, and if the Health Visitor has been in touch. There is a face-to-face discharge visit one week later. Visits are based on clinical prioritisation and women are seen if they have any issues or concerns with themselves or their baby. 

Postnatal discharge due to missed postnatal visits was identified as a risk in 2023. Significant progress has been made, but there is further work still to do. The following actions have been taken:

• Discharge lists are downloaded from BadgerNet to act as a failsafe for missed patients. 
• “Failsafe” within the community team is in place to identify all discharges within a 24-hour period. 
• Staff have been sent ‘how to guides’ for reminders about the criteria which require completion.
• The Inpatient / Community Matron follows up individuals who have missed a community referral.
• Communication about learning from incidents has been shared widely across the midwifery service by various platforms and at team meetings.
• The midwifery team checks that the discharge address is correct on BadgerNet.
• “Fail safes” are in place with the antenatal screening team to identify newborn blood spot (NBBS) test on day five visits.
• All out-of-area discharges are individually notified by telephone to the community midwife hubs.
• Newly appointed midwives have a full preceptorship programme, which covers postnatal discharge. 

With the implementation of BadgerNet electronic notes the pregnancy episode is automatically closed 42 days after the due date of the baby. However there remain challenges with a consistent approach to closing the care down on the system at discharge. This is being addressed through the community midwifery review with the reintroduction of postnatal clinics. Women are offered appointments for discharge within antenatal clinics, whenever possible.

You refer in your letter to the low morale within the community midwifery team, and some specific concerns in relation to the behaviour of some leaders. The Trust launched its new values and behaviours last year. Leaders in the service are focussed on ensuring our work environments reflect these expectations. Specific examples where concerns are raised have been addressed through HR processes, with support from the operational team and senior midwifery leadership. Poor behaviour is not acceptable. If reported, such behaviour is dealt with appropriately, using Trust policies. If concerns are raised about members of staff, steps are taken to discuss the concern with individuals. Repeat complaints from staff about the same person and/or people are monitored and managed according to our policies, which are in line with employment law and professional standards guidance. 

As part of our overall maternity improvement programme, there is a strong focus on culture and engagement. One aspect of this is encouraging staff to feedback in the moment through the roll out of a feedback tool. The Professional Midwifery Advocates (PMAs) and Organisational Development (OD) Consultants have organised sessions for staff on the professional management of difficult conversations. 

Turning to staffing, we have made significant progress in ensuring that our community services are fully established. There are currently no vacancies in the team leader posts and the Home Birth Team is also fully established. 

Elsewhere, there are minimal vacancies in community midwifery, and the pregnancy mentor role has been implemented permanently. Shared governance is being established in the service, and the Director of Midwifery has set up quarterly meetings with community midwifery staff to ensure there is a strong leadership presence and availability. To further support the team, three community midwives have been nominated to undertake Professional Midwifery Advocate training. The Organisational Development Consultant has supported community midwifery teams through community midwifery forums, individual team support and development. The teams will be undertaking the Affina culture and development programme this year. There are plans to realign the community midwifery teams so that there is greater support. This includes a business case to address estates issues so that teams have a base to work and meet. 

It is essential that we support our staff and women through strong community services and effective post-natal care. I hope this provides you with assurance that we value the community midwifery service, and we are working hard to improve them. I have visited these services and recognise their value. It is important that the community teams are integrated into or perinatal pathways.

4.     Governance

I recognise that our response times to Subject Access Requests (SARs) have not been acceptable. Despite significant investment and improvements in the service there are still delays. This is due to several factors, but one of the most significant is the increase in both the volume of SARs and their complexity. While this is particularly true in relation to maternity cases, this is a general theme. The “routine” requests for medical records are less of a challenge, and our response times are near the 30-day national target. However, where families require access to a range of other documents, such as e-mails, achieving a turnaround within 90 days is proving to be problematic, especially where the number of documents involved runs into several thousand.

Last summer we implemented a major organisational change in the department responsible for this service. This is designed to strengthen the team in the following ways:

• Creating a case-load approach across the department.
• Streamlining the approach to routine and complex cases.
• Enhancing the seniority of staff dealing with this work to improve recruitment and retention and develop ownership.
• Developing an apprenticeship programme to skill up the team to be able to deal with multiple types of data requests and improve customer services capabilities.
• Filling all vacancies across the department (this has been achieved, bar two roles)
• Strengthening the management structure.

Please be assured that this is a priority for us and progress is being monitored at a monthly oversight group. 

I recognise both through our conversations and through the details in your letter that it remains a challenge for patients and their families to navigate our services, and we often make this more difficult through complex processes. As you are aware, we outlined a fundamental change at our Annual Public Meeting (APM) with a focus on developing family liaison services with dedicated case management to support families through these systems. This should address the navigation issues you have identified and improve the translation and language challenges that have been reported. 

I am sorry to hear the concerns that have been raised in relation to postmortems, particularly as this is such as difficult time for families. We have worked on strengthening our bereavement services and support to families. It would be helpful to have more information on these cases so that we can investigate fully

5.     Staff voices

Thank you for sharing feedback from colleagues. Whilst work in this area is showing progress, I recognise the journey will be an iterative one. It is important for staff to work in a supportive environment and feel heard when they raise concerns. 

We continue to tackle reports of incivility or bullying and we take them seriously. The culture and engagement element of our maternity improvement programme is looking at themes. A feedback tool has been introduced to encourage staff to respond at the time, if appropriate, and share how the colleague has made them feel. The Professional Midwifery Advocates and Organisational Development Consultant have organised sessions for staff on having difficult conversations.

Since September 2023, we have significantly improved preceptorship for newly quality staff including midwives, we ensure the support is individualised to the newly qualified midwives (NQMs). There is a robust preceptorship team led by the workforce matron, alongside two part time preceptorship midwives and legacy mentors. We have recruited two more midwives to support our NQMs. The workforce matron ensures that all midwives offered a post at NUH have support and contact prior to joining the Trust. Start dates were staggered to ensure the clinical areas are not overwhelmed. I am assured that new starters have reported feeling well supported in the workplace. 

As is common nationally, our workforce is dependent on newly qualified midwives. However, we have recently recruited experienced midwives. We are pleased to have been successful in attracting midwives to the Trust in the last two years. As a result, we have increased capacity in the preceptorship team. We have retained most staff recruited in this period. There is a mix of experience within the maternity leadership team, with some experienced and long serving colleagues and newly appointed staff. 

Currently, we are implementing the national labour ward coordinators’ framework with the Band 7 team and, with input and facilitation by the OD consultant, have started 360 feedback. This helps personal development, based on responses from their peers and colleagues. Serious Incident reviews consider the human factors and environment at the time as factors which may have impacted the outcome. The Trust is implementing a Patient Safety Incident Response Framework (PSIRF) approach to incident management and Systems Engineering Initiative for Patient Safety (SEIPS) framework which will identify where poor escalation is a concern. 

The matron team has attended local leadership courses and regional aspiring Head / Director of Midwifery courses to improve their leadership knowledge and skills. It is disappointing to hear that you have had reports of members of staff having left the Trust due to “stress, anxiety and burnout”. This is not something that we have seen in our data. The workforce matron and HR team report the number of leavers and reason for leaving monthly. The themes from exit interviews and termination forms are retirement, relocation and promotion. No leavers have given stress, anxiety and burnout as a reason for leaving, but I acknowledge that an individual may choose not to share this. Our overall retention rates have improved significantly. For example, turnover was 14% in October 2023 and is currently 8%. 

Staff wellbeing is a primary focus, with support offered through the wellbeing team, Occupational Health, PMA support and counselling. Recruitment of clinical psychologists is ongoing specifically to support staff wellbeing. The executive and leadership team provide engagement events every month (as a minimum) to ensure staff are kept informed and have a forum to share concerns and receive support. 

The learning and improvement meetings, and the subsequent exchange of letters, provide invaluable feedback for our improvement plan. Your feedback ensures that we do not miss aspects of improvement. 

I hope this response addresses the points you make in your letter. I am grateful for all that you continue to do for local women and families, and you can be assured of my ongoing commitment.

Yours sincerely

Anthony May OBE DL

Chief Executive

18 December 2024

By email only:
 

Mr Anthony May OBE DL Chief Executive

Nottingham Hospitals NHS Trust Trust Headquarters

City Hospital Campus Hucknall Road Nottingham

NG5 1PB

 

Dear Anthony,

Further to our previous correspondence and recent conversations, I am writing to you to highlight some of the issues that have arisen as we progress the Review. We have agreed that our communication should be on an ongoing basis, rather than wait until the Review team have completed our work and we publish our final Report. The information within this letter therefore is still to be fully investigated by the Review and is informed to you as it is reported to us both by families across Nottinghamshire and current and former Nottingham University Hospitals (NUH) staff. This ongoing sharing of information and the continuing dialogue between ourselves, Tracy Pilcher, Chief Nurse and Dr Manjeet Shehmar, Medical Director at NUH all combine to assist the Trust in its ongoing perinatal improvement journey.

Following on from the Learning and Improvement meeting of 19th November 2024, and the Trust and my/ my team’s recent communication and meetings with local families and current and former NUH staff, I am writing to formally record the issues, concerns and positive feedback that has been discussed and shared with me.

At the time of writing there are 2022 families and 827 current and former NUH staff participating in the independent maternity Review, and as of today’s date and since June 2023 I have referred 112 families directly to Tracy Pilcher and yourself. These referrals occur where families have specifically asked that their concerns be shared directly with you as CEO. These are situations causing distress to families in the ‘here and now’ and need to be considered by the Trust without delay.

Of these 112 cases already referred to NUH, 43 are agreed by families, NUH and the Review team to be ‘closed.’ (‘Closed meaning that the family and the Review team are satisfied that the Trust has completed all necessary activity around a concern.) In addition, the Review team are in the process of liaising with families to ascertain if they are satisfied with the Trust's response in a further 15 cases. There are 30 cases where the Review team are awaiting further information or a supplementary request response from the Trust. Of the remaining 24 cases the Review team are actioning 12 cases and the remaining 12 cases are ‘overdue escalations’’’ awaiting a response from the Trust.

 

Overdue escalations requiring progress:

There are 12 overdue escalations for the attention of NUH:

As you are aware although the escalations have happened since June 2023 it is important to state that in some cases the escalations and family concerns span the whole time period of the Review. Should the NUH team require any information to identify individual cases/ families below, please do ask. The escalations where a response from the Trust is overdue include the following:

• An update on the Trust led investigation into the case of Mrs Anonymous 1 (Trust are aware of name) first raised with the Trust in August 2024
• Information on the progress of the Trust Linguistic Working Group, arising from the case of Mrs N: originally raised by the Review team in November 2023 and raised again in August 2024 following family feedback that the Trust response was insufficient.
• Information about whether the Trust escalated concerns with a temporary member of staff in the case of Mrs J, to the recruitment agency (escalated to the Trust in early September 2024).
• A copy of the complaint response in the case of Mrs L, escalated to the Trust in October 2023
• Information from the Trust on the completion or otherwise of the external review into the case of Mrs Anonymous 2 (Trust is aware of name), first escalated in October 2023.
• Information on the complaint response in the case of Mrs Anonymous 3 (Trust is aware of name), escalated to the Trust in August 2024
• Further information on the Trust’s response to the Review team ‘that there is a theme that clinical documentation does not reflect the experiences or lived experiences of families.’ The Trust advised the Review team in October 2024 that ‘a programme of audit and education/ training for staff is being developed.’ As you will recall this came from the case of Mrs Anonymous 4 (Trust is aware of name), escalated to the Trust in September 2024. This is likely to be a vital Trust work stream and as such we would ask we are kept involved regarding its progress.
• An update in the case of Mrs O, escalated to the Trust in June 2024. On behalf of Mrs O, we had asked for a rapid internal review so the Review team can answer Mrs O’s questions and possibly request an appointment with a female NUH gynaecologist. As almost 6 months has elapsed since we originally contacted the Trust, please can this be responded to as a matter of priority?
• An update in the case of Mrs Anonymous 5 (Trust are aware of name) escalated in June 2024, whilst we have been advised by the Trust that the ‘actions requested have been closed’ the Review team has no evidence with which to verify this claim.
• An update in the case of Mrs Anonymous 6, escalated in August 2024 who asked for additional support for her child to be provided by the Trust. We have yet to receive a response regarding this.
• In the case of Miss Anonymous 7we are advised the Medical Director was reviewing her records in October 2024. An update is still required.

1.  Concern with early pregnancy care and pregnancy loss - A23 ward at QMC:

This has been an issue of ongoing concern from multiple families and you will recall that following on from raising their concerns in April 2024 we met jointly with Mr and Mrs Anonymous 8 2 weeks ago.

In addition, and as already advised to the Trust, A23 staff came forward to the Review team and met with me at their request to confirm that the concerns raised by local families are accurate. Staff describe a poor infrastructure in A23 which they say is not fit for purpose.

Staff advised me that A23 at QMC is facing significant challenges in terms of resources, staffing, and lack of continuity of care. There is a concern from staff, (corroborated by multiple patients) that on many occasions A23 is failing to provide a reasonable standard of care with information from staff and patients indicating that the experiences of women and families are largely dependent on chance, described by staff as "pot luck." Delays in getting women scanned, sometimes for days, is said to be affecting service delivery, patient experience and damaging the unit’s reputation.

Staff advised me that ‘Management appears completely disconnected from the front-line operations and care giving’ with a lack of clarity about roles and responsibilities. There is, according to staff, a complete lack of awareness regarding the day-to-day challenges faced by front line staff. I am informed that the introduction of a new IT system, Badgernet, has been rushed and lacks sufficient planning. I have been told of concerns that there has been inadequate preparation prior to implementation. Staff advise me of a general lack of confidence in its success, with fears that it will not be integrated properly into the unit’s workflow. Please can this be reviewed?

I am advised by A23 staff that ‘several people have left the unit’ because of poor [senior] staff behaviour. The combination of all these issues is leading to a sense that A23 staff do not have a voice and have ‘nowhere to go’. Hence they have come to me. There is a general sense of dysfunction within the unit, with operations described by staff as "a mess" and a lack of streamlined processes. Staff feel stuck and unsure of where to turn for support. This has all been escalated to Tracy Pilcher as Chief Nurse who in turn has provided me with some very helpful updates on progress. However, due to the apparently very long term nature of the issues within A23 across what appears to be a number of years it is important that I brought these concerns to your attention directly through my periodic reporting to you.

With reference to medical leadership on A23 I am advised there is uncertainty from the front line clinical team about who is leading the unit. The manner in which some medical staff communicate with women has been flagged as problematic, and there is a perceived lack of interest and accountability from the medical team. There is further comment on this by mothers including one who recently asked questions of a doctor and was advised ‘Dr Google will explain.’ Staff have expressed concerns about the knowledge base of some doctors, particularly in relation to the reliability of care being provided, with some describing the situation as chaotic. Junior doctors in A23 are described as lacking adequate support and interest from senior colleagues.

Staff have also raised concerns with me about the care of patients on A23 who are unwell or bleeding heavily. There have been concerns expressed of transfers to A23 from the Emergency Department (ED) which A23 staff describe as sometimes ‘unsafe.’ I have been told of patients brought to A23 from ED with little or no information about their condition and left to sit in waiting areas bleeding heavily and with no handover. Recently, I am advised that staff from ED handing over a patient to A23 have actually been unable to handover as they have not known the patient history. Additionally, I am advised there is inconsistency in the prioritization of A23 patients, particularly with regards to the timing of when they are seen.

Staff have advised me that women at 16+ weeks of gestation are treated differently from those at 20+ weeks, depending on whether they are booked for maternity care at City or QMC, (I have previously raised this with the Trust) thus leading to discrepancies in care. NUH staff have also told me that both miscarriage and fertility support for staff is ‘shocking. ’ (A member of NUH staff recently told me that in 2020 at the time of her fertility treatment and subsequent miscarriage she was treated the same as if she was absent from work following cosmetic or plastic surgery; with a complete lack of care and compassion), I am advised by staff (and would ask that you check) that time off for fertility treatment remains poor at a maximum of 2 weeks every 2 years. I am also told by NUH staff that the policy underpinning this decision was written by the Trust without any input from staff who had experienced fertility treatment. NUH staff still tell me that pregnancy loss support from NUH as their employer remains ‘non-existent.’

Through the maternity and antenatal experiences work of the Review both mothers and fathers also continue to raise concerns about the care and treatment received on A23. I have already escalated to you the concerns about A23 from Mrs Anonymous 9 who experienced an ectopic pregnancy in the summer of 2024. Having had a previous ectopic pregnancy Mrs Anonymous 9 described to me that she knew what was happening to her and tried to communicate with numerous staff in A23. Over a time period of 9 days Mrs Anonymous 9 described how her concerns were not listened to by staff on A23 and ultimately the outcome for her was poor. Mrs Anonymous 9 described how medical staff told her of the need for surgery in an area where the conversation could be overheard, thus breaching her confidentiality.

Another example from A23 raised by a mother who wishes to remain anonymous (having used A23 for a number of pregnancy losses since 2020) has already been escalated to the Trust. This mother describes her care by NUH during her miscarriages as ‘disgusting’. The mother told me that in 2021 she attended A23 when it was clear she was losing her pregnancy and was shouted at by 2 members of staff. After being told she had lost her pregnancy she was offered no aftercare or information and told ‘some people don’t even know they are pregnant at this stage…what is 6 weeks…?’

In further miscarriages she tells me that A23 staff told her to collect evidence of her miscarriage (as she said to me ‘my babies’ ) in a kitchen sieve over the toilet at home and then transfer from the sieve to a plastic box which she should keep in her home fridge. When they took the plastic box in to A23 as instructed the family were offered back the rinsed out container. Mrs Anonymous 10 described to me she and her partner had no support, no aftercare, just unexpectedly a letter from the Trust several months later saying that she had miscarried a ‘baby girl that was … normal…’ Mrs Anonymous 10 told me that her miscarriage in summer 2022 was extremely traumatic when she passed the baby in the QMC car park. A23 staff would not accept her even though she was able to describe to them exactly what was happening/ had happened. Instead she was told to go to ED where she described to me having a speculum examination to remove the remains of her pregnancy. Mrs Anonymous 10 said to me that prior to the speculum procedure ‘there was no consent, no pain relief, no discussion, I was just left there…’

When Mrs Anonymous 10 asked NUH staff for support from specialist midwives after her multiple pregnancy losses she was told by them that such midwives are only for people ‘who have had babies.’ Her partner was never asked if he needed support or further information. Another mother Mrs S described to me how following experience of a number of miscarriages from 2018 onwards, when she was able to become pregnant and her pregnancies had happier outcomes she actively chose to receive maternity care in a service other than NUH. She avoids care at NUH as much as she can describing to me her pregnancy loss care in A23 as ‘inhumane’ with a staff member saying to her: ‘I can’t talk to you, I have another patient waiting… please leave the room…’ Overall, Mrs S remembers A23 to be as impersonal as a ‘McDonald’s drive through;’ please note this description was not intended as a criticism of McDonald’s.

Mrs S now has a child requiring paediatric intensive care on an ongoing basis and therefore does need to use the NUH PICU service for her child. Mrs S is full of praise for the PICU service. I have already highlighted her praise to yourself, Tracy Pilcher and Dr Manjeet Shehmar. Can you please confirm that this has been shared with staff?

Postnatal care:
Since the last Learning and Improvement meeting a former member of staff has come forward to me to raise concerns regarding the provision of postnatal community midwifery care by NUH this year.

The staff member who remains in contact with former colleagues still working at NUH stated that senior midwifery leaders were (and are) unaware of what was happening in the community and did not show an interest in understanding the service. The staff member highlighted the lack of engagement and knowledge during meetings, where senior midwifery leaders often failed to answer questions due to a lack of information. I was also told that a key member of the senior leadership team did not (and still does not) understand the challenges faced by community midwives. Engagement with (and support of) NUH’s community midwifery staff by their managers is said to be particularly poor especially when community staff are absent from the service as a result of stress-related sickness.

It was also emphasized to me by the former staff member that there was, (until very recently) an ongoing issue with new mothers receiving inadequate postnatal care at home following discharge from hospital. I am advised that staffing difficulties sometimes led to ‘postnatal care’ comprising of midwives only able to make telephone calls for follow up leaving new mothers and their babies without visits or assessments. I was further advised that discharges from community midwifery care were often cancelled including this year, leading to gaps in care. In response (and as already requested), please let me know when this concern was added to the maternity risk register and how this concern was escalated through the maternity service to the Divisional team and beyond. Please also advise whether this is still ongoing or when it stopped and how the Trust ensures that new mothers and families were/ are kept safe in the postnatal time. (I am advised these concerns were raised multiple times by community midwifery staff).

The morale within community midwifery services was described as being low, with some managers and senior clinical staff being described as "horrific." Former staff mentioned that one team member had to be managed for bullying behaviour, contributing to the poor atmosphere. Current staff in the community midwifery service are said to remain in contact with this former employee, and therefore it is advised to me that that some of the concerns as set out above remain current.

Governance:

1. Families are still regularly reporting to the Review team (and we are seeing evidence of) a significant delay in response to requests for medical records and a delay in complaint responses. An example is a family who wrote a detailed letter of complaint to the Trust in early August, now 4 months ago and told me last week: ‘We just expect an apology for the continuing delay in our response at the start of the month..’ It was previously agreed it is important that the Trust ensures that the team investigating patient or family concerns or providing records to individuals are appropriately staffed/ resourced to ensure that these concerns are responded to in an appropriate timeframe. Families advise me this is still not happening consistently.
2. I raised with you in my last letter and since then following feedback from the Family Psychological Support Service, (FPSS) and the recent family meeting, how many families are struggling with the difficult process for submitting the documentation requesting their own records or Subject Access Requests. There are 2 issues raised by both families and FPSS, first the need for multi lingual explanation in the languages most commonly spoken across Nottinghamshire and secondly the need for the process to be written in ‘plain English’ rather than jargon so that all affected families are able to understand what they need to do. Families continue to raise the issue of ongoing delays in receiving information from Subject Access Requests.
3. I have previously escalated the case of a further Mr and Mrs Anonymous 11 whose baby son was stillborn at term this year. A recent NUH report into the care provided to Mrs Anonymous 11 late in pregnancy showed that if different care had been provided then their baby would in all likelihood have survived. I have recently met with the family as they wanted to tell me their experience of the investigation processes in place in NUH. As I have explained to you they have highlighted the ‘defensive’ attitude of some members of NUH staff involved in the investigation process. When asking for a meeting to look at their concerns they were informed that their concerns had already been looked at in previous meetings.
4. Mr and Mrs Anonymous 12 also described to me that they felt they were being dissuaded by some NUH staff from having a post mortem examination of their baby. However, their ultimate decision as parents was that this was what they wanted to do. Following on from completion of the post mortem examination they should have been able to have started confirming funeral arrangements and dates for the funeral for their baby. However there was no confirmation of the completion of the post mortem process so ultimately there was a delay in their baby’s funeral. The Trust told the family that the funeral director was to blame for this lack of information. To ensure I understood what should have happened I have checked this generally with a number of funeral directors outside of Nottinghamshire; they all advise me that the responsibility for informing parents that the post mortem examination is complete remains with the Trust.
5. Associated with this case I asked you and Dr Shehmar to please pass on the thanks of Mr and Mrs Anonymous 13 to Dr Walker, consultant obstetrician who they described to me as treating them with dignity, respect and compassion during a tragic time for their family.

Staff voices:

6. At the time of writing many maternity staff are still reporting to the Review team significant distress at the working conditions within maternity services at the Trust. These are said by staff to both predate the commencement of the Review in 2022 and in a number of cases to still be continuing. For the avoidance of doubt staff raising concerns are clear that it is not the Review or its processes that causes their distress and multiple staff have confirmed how glad they are that they have the Review team to talk to. Recent issues reported by staff to the Review team include the following:

• Very long term and continued feedback from a range of staff about the ongoing presence of known bullies within senior clinical midwifery roles.
• A lack of support for newly qualified midwives, (NQM) and bullying and belittling of newly qualified midwives, sometimes in front of patients. This is especially reported as happening where NQM raise concerns that they do not know something or they cannot manage their allocated workload.
• The workforce is highly dependent on NQM and the skill mix is frequently poor.
• NQM midwives frequently been given a higher workload/ intensity of workload than more experienced midwives
• Inconsistent quality in local leadership and management with unapproachable labour ward coordinators leading to poor escalation of significant concerns.
• Members of staff having left the Trust within the last year because of stress, anxiety, and burnout.

In conclusion, my sense is that I am continuing to hear from both current and recent staff members and families about significant concerns. Many of the families are those who my Review colleagues or I have met recently or have contacted the Review team to report concerns that are of current or recent origin. Similarly staff concerns are frequently of very recent origin.

I trust that my letter is helpful in ensuring that the Trust’s perinatal services continue on their improvement journey

Yours sincerely

Donna Ockenden Chair

The Maternity Review

Nottingham University Hospitals (NUH) NHS Trust Donna Ockenden Ltd

Copies:

Tracy Pilcher, Chief Nurse, Nottingham University Hospitals NHS Trust

Duncan Burton, CNO, NHS England, Chair, Learning and Improvement Meeting

Professor Nina Morgan, Chief Nurse, NHSE Midlands Region

Greg Reilly, Deputy Director of Operations, CQC

Chief Executive’s Office
Trust Headquarters
City Hospital campus
Hucknall Road
Nottingham
NG5 1PB

Dear Donna,

Thank you for your letter of 1 July 2024. As always, I am grateful to you for providing feedback to support our ongoing perinatal improvement journey. I am grateful, also, for the open and transparent way in which you are conducting your review. I believe this approach will benefit all those affected by the review, particularly women and families. Please accept my assurance that we will continue to learn from your feedback and incorporate it into our Maternity Improvement Programme.

I want to acknowledge the concerns being expressed by both women and families, and colleagues who work in Maternity Services. It is important that we address the feedback you have received. I hope you will be reassured by the range of actions, set out in this letter, which we are taking to improve the quality of our maternity services. I know we have a long way to go, but we are committed to your review as a key part of our improvement.

As part of our commitment to supporting your review, and the requirement to address the concerns of families, we have invested in a team to review the cases you have referred to the Trust. Recruitment is largely complete, and I anticipate this will lead to an improvement in our responsiveness. This investment will remain in place for the duration of the Independent Maternity Review (IMR). In addition we are working on a stronger approach to family liaison, which I plan to present at the Trust’s Annual Public Meeting on 18 September 2024.

I will address the remainder of your concerns following the thematic approach you have used. In so doing there may be a degree of overlap between the sections.

Governance
Improving our responses to Subject Access Requests (SAR) and complaints is a priority for the Trust. We have made a number of improvements, but there is still more to do. We have restructured the team which deals with SARs, Freedom of Information requests and access to medical records. In July 2024, 14 new colleagues were appointed and will commence throughout August and September 2024, with more posts in the process of recruitment. This should move the service into a period of stability over the next three to six months. In the meantime, to bridge the gap, we have offered existing staff overtime and reviewed business processes.

A new IT system (Core-Stream) was implemented in January 2024 which ensures the streamlining of requests. There has already been a considerable improvement on outstanding cases. This should continue to improve, although it will take some months to catch up on the Trust’s significant backlog.

In addition, we are working hard to improve our response to complaints. Overall, our complaint response rate has improved this year, and by increasing staffing in this area we are focussed on maintaining that trajectory. The challenge in relation to quality is accepted and recognised. Our new Chief Nurse is looking at this as a priority.

The process for requesting access to health records is also under review, although the provision of the minimum personal information is a requirement of the Data Protection Act. Nevertheless, our Chief Digital and Information Officer is charged with revisiting how the system is navigated and the guidance notes. We are committed to simplifying the process and improving the supporting information.

The use of inappropriate language in emails is entirely unacceptable and I apologise unreservedly to anyone who has been affected. Potentially, inappropriate language and exchanges in emails is a disciplinary matter. Any specific examples will be properly dealt with in line with our HR professional standards arrangements. To tackle this issue, I have taken the following actions:

• I have written to the Trust’s Chief Digital and Information Officer to ask him to ensure that proper quality assurance arrangements are in place so that examples of inappropriate language and/or professional standards are flagged.
• I have written to the Trust’s Chief Digital and Information Officer to ask him to review the Trust’s policy for email communication, with a view to re-launching it with an offer of appropriate training and support.
• I have written to the Chief Nurse and Medical Director asking them to deal with inappropriate language in emails as a professional standards issue.
• I will be writing to all staff in the Trust to remind them of their obligation to communicate in a professional and courteous way.

Follow-up of cases referred to the Trust

I am committed to ensuring that we take every possible step to satisfactorily address all concerns raised with us. That said, I am mindful that some families have indicated to the Trust that they do not wish to pursue a matter further. If these, or any other family, would prefer us to communicate through your office, we would be happy to do so, provided we have their consent. This arrangement might apply, also, where a family may not regard a matter as “closed”, and indicate as much to your team. In these instances, I hope we can work together to find an acceptable form of closure recognising that a family might prefer to receive responses via you rather than directly from the Trust.

I can confirm that (at the time of writing) backlog in birth debriefs has reduced from eight months to eight weeks. This is a significant step in the right direction, but one which I recognise needs to be built on.

Poor hygiene and cleanliness

Both your feedback, and the recent CQC inspections, highlighted instances of poor cleanliness on ward areas. For example, the CQC raised an issue in relation to the curtains around beds.

I am grateful for this feedback. This is disappointing. It is something we have responded to the CQC on directly, and have taken direct action to address the points raised during the recent unannounced inspections. Moreover, one of our Heads of Midwifery has been leading a programme of work with our Band 2 and 3 staff focussing on wider responsibilities including ward hygiene, communication, and staff attitude and behaviour.

Lack of kindness and civility

Women and families using our services have a right to expect kindness and civility at all times. I apologise to anyone who has experienced anything less, including anyone who has experienced racism, which is unacceptable in any form.

In your letter, you raise some specific instances of rudeness. I would be happy to receive further details of the case of Mrs M so that this case can be properly investigated.

Your letter makes reference to poor, and sometimes rude, verbal communication. I have asked the Director of Midwifery to make my expectations clear, that all staff at NUH are expected to communicate in a professional and courteous way at all times. I have reminded our Chief Nurse and Medical Director that unacceptable communication of any kind must be dealt with as a professional standards matter. There are clear processes for issues such as this and we must follow them to an appropriate conclusion.

You have highlighted concerns about how we communicate with and involve fathers, particularly when the pregnancy is not straightforward. I am sorry to hear about these concerns. I would like to assure you that we are committed to ensuring that the care of the father and birth partners is an essential part of our maternity care. We have strengthened our approach to this through training and education programmes. One example is the training provided through Practical Obstetric Multi-Professional Training (PROMPT). There is a designated person to look after the partner and keep them informed of what is going on during emergencies. They escort the partner to theatre, for example, when they need to get changed. We encourage partners to attend postnatal debriefs and birth reflection appointments. Questions from partners are encouraged during any investigation as we recognise the impact that birth trauma can have on them.

More broadly, as part of our People First Strategy, we have launched a new set of Trust values. While I recognise that embedding these will take time, they reflect much clearer messages to all, and we will use them to hold each other to account. Our new values are:

• Kind – We are compassionate and caring to everyone
• Inclusive - Everyone is welcome
• Ambitious – We continuously improve
• One team – We achieve more if we do it together

The values link with our newly published Workforce Inclusion Strategy approved by the Trust Board on 11 January 2024 (attached). This Strategy is accompanied by a comprehensive implementation programme.

In my letter dated 22 February 2024, I described some of the work to respond to your earlier feedback about inclusion in maternity. This work continues, alongside the wider work we are progressing through our Community Engagement Team. This team is focussing on fostering connections with local charities and communities in Nottingham to enhance healthcare access and outcomes. The team has prioritised a number of key initiatives, including:

• Specialist clinics (including support for diabetes, female genital mutilation, etc) are being moved from hospitals into the community to improve attendance and access.
• The establishment of an Inclusive Maternity Task Group, which is dedicated to reducing inequalities and improving outcomes.
• Collaborations with charities and community groups such as Heya and the Mojatu Foundation.
• Partnerships with local organisations including church groups, universities, the Muslim Women’s Network, and the East Midlands Ambulance Service (EMAS).
• The development of Cultural Awareness Training, including introduction sessions during Impact Day for Midways and Maternity Support Workers, and a full day program for the MDT.
• Work to increase workforce diversity via an ongoing programme of recruitment from schools, universities, and local industries. Recruitment initiatives for midwives, both internationally and locally, have also increased diversity.

Your letter raises issues about our postnatal care. I am aware that some of our postnatal care requires further attention, as we have too many examples of discharge processes to primary care not being sufficiently robust.

We have undertaken some detailed work in relation to missed postnatal visits, and a report issued earlier this year captured a comprehensive programme of actions, including:

• Improved training and preceptorship packages.
• Failsafe processes, including a daily discharge list to monitor cases.
• Direct contact telephone numbers for mothers to call if they have not been seen on time.

If you are able to share specific examples of problems being reported to you, I would be happy to look into them.

Staff related matters

I am pleased that so many colleagues are taking the opportunity to engage in the staff voices element of your review, and we are grateful for the feedback that it provides.

I recognise the concerns that staff have raised with you. I have apologised publicly to colleagues who felt the need to raise issues directly with you or our regulators. This is concerning and indicates that we must work on how we communicate with staff across maternity. This is an issue that our new Medical Director and Chief Nurse will be addressing. As a means of reassurance, we have a comprehensive programme of support in place, which I have summarised in Appendix A to this letter. It seems, though, that we must do more to make colleagues aware of what is on offer, and to do more to understand the needs of colleagues who are working in a busy service, which is under intense scrutiny.

In relation to staffing, duty rotas and the allocation of shifts can be contentious, but our process includes the check of all ward produced rosters by matrons and the workforce lead.

This ensures that the skill-mix for each shift is appropriate, that flexible working arrangements are honoured, and that there is no obvious imbalance in shift allocation for individuals.
Specifically, I can confirm that:

• All staff have the ability to request shifts off.
• Flexible working agreements are supported as much as possible, with regular review.
• The labour ward coordinators’ competency framework is being delivered and is due for completion by October 2024, when self-assessments are completed.
• Bullying behaviour is not tolerated and is dealt with through the HR process when reported.
• There is a focus on feedback and speaking up. This includes appropriate support from our Freedom To Speak Up Guardians, a dedicated Organisational Design lead and a dedicated HR business partner. This reflects a concerted effort to improve the confidence of staff to raise concerns.

In relation to Newly Qualified Midwives (NQMs), it is the case that these are the main source of new staff as there is very little movement of experienced staff locally or nationally. Please be assured that we have developed a robust infrastructure to ensure a balance in the workforce between numbers and skillset. As a reflection of the way in which we support new colleagues I can report that all NQMs who have been employed in the last 12 months have remained at NUH.

Features of our support and development mechanism include:

• All NQMs have a fully supported preceptorship programme for a minimum of 12 months.
• All NQMs have a minimum initial four week supernumerary period with an additional two weeks when inducted to a new area; this is individualised according to need and working hours.
• Band 5 progression to Band 6 is supported as soon as 12 months post registration and on completion of the preceptorship pack.
• Rotational contracts between community and acute service are in place to maintain competence and confidence across the service and to prevent loss of experience into community.
• Staffing concerns discussed and escalated at daily MDT cross-site meetings supported by the operational and senior leadership teams.
• Teams are supported by non-clinical midwives and management when needed.

We have completed the Birth-Rate Plus acuity tool as per guidance with escalations and actions, including escalation to the manager on call. The Trust meets the Birth-Rate Plus standards and recruitment is positive with 40 midwives scheduled to join NUH in the coming months. In addition, we have sufficient budget to recruit above Birth Rate Plus, to take into account some of the unique factors which impact on our maternity services. Equally, despite the Trust’s ambitious Financial Sustainability Plan, maternity services are not expected to make specific savings.

All of these measures are supported by the senior leadership team. The team has made efforts to be visible. This includes a daily walk around by matrons and/or Heads of Midwifery, as well as a monthly Heads of Midwifery visit to the community team base. In addition, the Heads of Midwifery and the Director of Midwifery are based within the maternity unit at City Hospital, and there is identified office space for them to spend two days a week at QMC.
Monthly engagement events, open to all maternity and neonatal staff, cover a range of topics, and front line colleagues are encouraged to voice any concerns or raise questions with senior colleagues.

Your letter mentions feedback from internal investigations. NUH has embraced the Patient Safety Incident Response Framework (PSIRF). PSIRF focusses on systems and processes, rather than individual fault. PSIRF emphasises a just and restorative culture framework used for responses to incidents (including HR related matters). Support is in place following incidents, for example hot debriefs, Professional Midwife Advocates (PMA), Quality Review Service (QRS) support, and Multi-Disciplinary Team (MDT) review of incidents (which has a learning focus).

Colleagues affected by incidents are supported through education, learning and reflection and through restorative practice models. In addition, we have improved support from our Legal Services for colleagues who are called to the Coroner’s Court.

Lastly, your letter mentions resourcing of community clinics. A community midwifery review is under way to consider estates issues, connectivity, team numbers, activity and caseloads, as well as administrative support. Rest assured, that administrative support to these teams has remained in place, pending the outcome of the review.

In summary, I hope that this response reassures you that we take your feedback seriously and that we have acted upon it. At the same time, I hope you can see that our Maternity Improvement Programme remains a high priority for the Trust, as does your review and responding to any findings from the CQC.

I look forward to continuing our work together in the coming months.

Yours sincerely

Anthony May OBE DL
Chief Executive

Donna Ockenden Ltd. First Floor, 31 North Street, Chichester, West Sussex, PO19 1LX
VAT No: 168 5906 65 - Registered in England & Wales - Company No: 8604834
Registered Office: 3 Lion Street, Chichester, West Sussex, PO19 1LW

1 July 2024

By email only:
Mr Anthony May OBE DL
Chief Executive
Nottingham Hospitals NHS Trust
Trust Headquarters
City Hospital Campus
Hucknall Road
Nottingham
NG5 1PB

Dear Anthony,

We have agreed that we will tell you about the issues that are coming up in the course of the Review's work on an ongoing basis, rather than wait until we have investigated fully and are able to publish our analysis in our final Report. The information in this letter therefore remains to be fully investigated by the Review and is as reported to us by families and NUH staff communicating with the Review. I sincerely hope that this timely sharing of information will significantly assist the Trust in its ongoing maternity improvement journey.

Following on from the from the Learning and Improvement meeting of 22nd May 2024 at the Trust, and my many recent visits and meetings with local families and current and former NUH staff as agreed, I am writing to formally record the issues and concerns that have recently been discussed with me.

In between Learning and Improvement meetings there is ongoing and regular contact between my team, myself and Trust colleagues. This is important as part of the Trust maternity improvement journey. I am grateful for the Trust’s engagement with the Review team and particularly with Tracy Pilcher, the Chief Nurse and yourself.

In the last month I have met with many hundreds of local families; individual and face to face meetings have continued, plus the Review Team hosted a family ‘Get Together’ attended by over 200 Review families. Last Sunday I also attended 4 church services with large congregations hosted by the Majority Black Led Churches, (MBLC) across Nottingham. In the last month I visited both City and Queens Hospitals early in the morning to informally meet maternity and neonatal teams ‘on the ground’ and to encourage them to join in with the Review’s ‘staff voices’ initiative if they have not already done so.

As at today and since formal records began in June 2023 I have referred more than 70 families to Tracy and yourself where families have specifically asked that concerns they have should be shared directly with you as CEO. These are situations causing distress to families in the ‘here and now’ and need to be considered by the Trust without delay. Essentially they are not concerns that should or could wait for the completion of the Review and publication of our final report. Unfortunately, a number of these cases are re- referrals where the Trust had told the Review team that the case was closed but the family have disagreed and asked me to advocate for them in this regard. A number of the concerns outlined in this letter are of very recent occurrence.

The concerns for the urgent attention of you and / or the senior leadership team at NUH include the following:

Governance:

1. Families are regularly reporting to me (and we are seeing evidence of) a significant delay in response to requests for medical records, delay in complaint responses, poor quality complaint responses, and continuing uncertainty as to whether an investigation was instigated as it should have been at the time of the incident. The delays in receipt of medical records following request to the Trust was a very significant concern raised by numerous families at the ‘Family Get Together’ on Saturday 15th June.

2. Families have also raised with me the very difficult process for submitting the documentation requesting their own records. I have briefly reviewed the document. I am unsure if this is used NHS wide or it is specific to NUH? It appears to ask some rather intrusive questions and would not be easily accessible to families without an advanced level of education. I am aware of families having to help each other to fill in the request form where families are distressed at not understanding what they need to do. This is causing limited access to medical records for those families who are isolated and do not have access to other families to help them.

3. We are both aware of horrible internal emails that have been written about families by Trust employees in recent years and subsequently sent to families in response to ‘Subject Access Requests’ made by families in the last few months. These are internal emails between Trust employees specifically mentioning families in the last few years. I am not suggesting for one moment that these emails should not have been provided to families by the Trust in response to a subject access request, but observe that they should not have been written about families by NUH staff in the first place. I hope that appropriate standards of email behaviour and etiquette can now be swiftly introduced and monitored within the Trust.

4. We both agree that it is important that the Trust ensures maternity governance teams (and any other teams) needing to investigate clinical or family concerns or provide records to families are appropriately resourced to ensure that these concerns are looked into and responded to as required in an appropriate timeframe. This is still not happening consistently and is compounding the grief and distress families experience after traumatic events at the Trust.

Follow up of cases referred to the Trust:

5. We are both aware of a number of cases referred to the Trust by me/ my review team that now need re escalation to you/ your team because the required actions have not been undertaken by the Trust. There appears to be a discrepancy in some cases where according to the Trust mothers have stated they did not want follow up appointments for birth injuries etc. even where there were complications significantly affecting the daily lives of mothers such as incontinence. Some mothers have said this is not true, with one who described to me being shouted at by a Trust employee on the telephone. ‘Do you want this appointment or not? YES or NO? One word, is all I need!’ (Trust employee to mother) The Trust employee was asked to ‘slow down’ so that the mother could explain that English was not her first language and allegedly the Trust employee (unidentified) put the phone down and recorded that the mother did not want the appointment.

6. In another case needing ongoing follow up for post birth care the psychological support service have had to highlight to the Review team an extremely long wait for maternal treatment of a year despite the case originating in the death of a baby at the Trust. This case has been referred to the Chief Nurse and yourself; I hope this can be swiftly resolved by the Trust so that the mother has the treatment she needs very soon.

Poor hygiene and cleanliness in the Trust negatively impacting on patient experience.

7. We are both aware of very significant concerns regarding hygiene and cleanliness that have been raised many times over the last few months. The examples within this letter are of recent origin, although lack of cleanliness also features in many cases throughout the timespan of the review suggesting it is possibly a chronic (and to date), unresolved issue at the Trust.

8. Recently Mr and Mrs R who sadly lost their baby in the spring of 2024 described an allegedly clean room where the bed had clearly been slept in (and smelled really stale), the toilet was soiled with faeces and a blood stained rag was found in the pull out chair.

9. Mr and Mrs V have also raised very significant concerns regarding the cleanliness of a number of clinical areas and lack of standard infection prevention processes across the Trust. This included a member of medical staff using a clinical waste bin lid as a sterile field instead of an appropriately prepared trolley for a highly invasive procedure. Mr and Mrs V shared further concerns with a soiled bed said to be clean, (I saw the photographs) and what appears to be insects in the bed and throughout the room. (These experiences as described by the R and V families were 2022 to 2024 and included gynaecology, maternity and neonatal units.)

10. You will recall that this is not the first time I have raised cleanliness of clinical areas and indeed a caller raised this with you ‘on air’ when we spoke on Kemet FM radio station recently.

Lack of kindness and civility; racism and discrimination.

11. As we are both aware these issues have been a longstanding theme throughout all of our conversations and communication since September 2022. It continues. We are aware of, and the Trust is investigating, some cruel and callous communication with a recently bereaved mother. Another mother with a 9 month old baby, Mrs M has told me that having had 3 babies in 5 years at City Hospital she feels there is a deteriorating level of civility at City Hospital. Mrs M believes that racism played a part in the way she was treated recently. She buzzed for help but was routinely ignored, staff would look up but ignore her. She reports that if staff did come to speak to her they would be rude, dismissive and tell her off. Other families are also reporting unkindness and rudeness which is believed to be linked to racism.

12. A mother who wishes to remain anonymous, (the Review team knows who she is) told us of support workers shouting at mothers and telling them off. There are a number of mothers now raising this concern. Mrs Anonymous was shouted at in front of other patients: ’What do you think you are doing? Stop that noise!’ Mrs Anonymous was rocking her baby in the cot as she was unable to pick the baby up post caesarean section.

13. Fathers and partners have reported significant distress at sometimes not being informed when mothers are experiencing complex deliveries; interventions were frequently not explained; and partners report being left alone with no information for long periods.

14. Postnatal care in the community appears to be poor in those cases where additional support has been necessary. Families report that staff appear to be under significant pressure with insufficient staffing for the workload they have. Many families are sympathetic to staff and comment on how very many of them are doing their best with the staffing available.

15. The Review Team hear multiple reports of poor signposting and access to professional psychological support following birth trauma which the Review team is now working with FPSS to resolve.

Staff voices:
16. I am pleased to confirm that more than 750 staff have now come forward to the Review’s staff voices initiative. Many staff are reporting significant distress at the working conditions within maternity services at the Trust. These predate the review and some distress exists to the current time. Recent issues reported by staff include the following:

• Lack of flexibility with work patterns, with favouritism as to who gets (or does not get) requested working patterns, the service is very ‘cliquey’ with known bullies at band 7 level.
• A lack of support for newly qualified midwives and bullying of newly qualified midwives, (NQM) sometimes in front of patients, particularly where NQM raise concerns that they do not know something or they cannot manage their allocated workload.
• The workforce is highly dependent on NQM and the skill mix is frequently poor.
• Inconsistent quality in local leadership and management with unapproachable labour ward coordinators leading to poor escalation.
• Previous members of staff having left the Trust because of stress, anxiety, and burnout.
• Poor visibility of the senior leadership team.
• Poor feedback and subsequent support following internal investigations; lack of support for colleagues involved in investigations; tendency to ‘blame’, rather than to learn.
• Concern was raised again this week by community staff around the lack of resourcing of clinics, in areas of high need and deprivation. There appear to be continued threats of possible removal of administrative staff from the clinics who from the perspective of community midwives are essential to the safe running of the clinics. You will recall I discussed this with Tracy Pilcher and yourself several months ago but community staff are raising concerns again in conversations with my team and say that their concern regarding this is heightened not reduced.

My sense is that I am now hearing a growing level of concerns from family and staff meetings rather than a reduction, and many of the families I have met recently or have contacted me to meet report concerns that are of recent origin. Similarly staff concerns are frequently of very recent origin or very much ‘in the here and now.’

I trust that my letter is helpful in ensuring that the Trust’s perinatal services continue on their improvement journey.

Donna Ockenden
Chair
The Maternity Review
Nottingham University Hospitals (NUH) NHS Trust
Donna Ockenden Ltd

 

Our Ref: AM/co
Chief Executive’s Office
Trust Headquarters
City Hospital campus
Hucknall Road
Nottingham
NG5 1PB
Tel: 0115 840 4807
Email: anthony.may@nuh.nhs.uka
www.nuh.nhs.uk
22 February 2024

Donna Ockenden
By Email: donnaockenden@donnaockenden.com

Dear Donna,
Thank you for your letter, dated 19 December 2023, and for the feedback it contains. This regular feedback is valuable in assisting our ongoing efforts to improve our Maternity Services. Thank you also for recognising the significant amount of work undertaken in our Maternity Service and for highlighting the provision at the Mary Potter Centre. Your feedback identifies areas where we must do better. Aspects of your letter make for difficult reading. Whilst it is disappointing to learn of the experiences which have been shared with you, I want to assure you that we are learning from the feedback. On behalf of the Trust, I want to apologise to these women and families for any shortcomings.

We know we have much more to do and we are focussed on improving our services. In modern Nottingham and Nottinghamshire, an important feature of quality is cultural sensitivity and inclusion. I want all our services to be inclusive and I want all of our patients and their families to engage with our services safe in the knowledge that they are open to them at all levels and free of discrimination. I hope that this letter shows our determination to address these issues as quickly as we can.

1. Translation and Interpretation service provision - You highlight that Roma women have raised lack of, or poor interpreting and translation services, including access to female translators during appointments, hospital care, clinical procedures, decision making and consent.

The Trust is committed to ongoing engagement across the communities we serve. We want to learn from our service users’ experiences and have recently appointed an Inclusion Fellow to lead the work, and to meet with targeted community groups.

Our Inclusive Maternity Working Group is working with the Trust’s Inclusion Team to develop five key actions. These are outlined within the Trust’s Workforce Inclusion Strategy, which was approved at our January 2024 Board meeting. The areas of focus are as follows:

• Improve interpreting services and accessibility.
• Develop cultural competency training for all staff.
• Increase engagement with local community groups, initially prioritising Black, Asian and Ethnic Minority women with a view to expanding this for all nine protected characteristics. We are rolling out clinically-led workshops with key community groups in venues that they use within their communities. This will help us hear about the experiences of these women and answer their questions. We will also provide updates on the improvements we are making in Maternity.
• Increase diversity within the Maternity workforce.
• Develop bi-lingual antenatal education forums.

The priorities for improvement have been identified through listening to service users. This includes community events for women from ethnic minority backgrounds, and through a questionnaire. Our Workforce Inclusion Strategy is overseen by our new Director of Inclusion. The strategy has a clear governance structure to ensure senior oversight, leadership, escalation, assurance and support. This structure is included in the appendix to this letter.
The feedback from the Roma women’s experiences has been shared with the Trust’s Inclusion Team, Maternity Leadership Team and the Trust Interpreter and Translation Services Lead.

The following actions are being taken to address these issues:

• A visit is being organised to the Mary Potter Health Centre this month to learn about the service provided to Roma women. We will listen to their experiences and consider what we can adopt across our services to enhance Roma women’s patient experience, translation services, informed decision making and consent.
• The Trust’s Interpreter and Translation Services Lead is considering alternative options to improve translation experiences for Roma women. We have agreed provision of face to face, video and telephone, female Roma (Romani) interpreters (when given advanced notice) from February 2024.
• The Maternity Team has secured funding for the ‘Cardmedic’ translation App, which will be launched this month. The App includes Romanian and Polish translation.
• The Maternity Ward clinics are piloting a ‘Pocketalk’ translation device from 26 February 2024. Pocketalk provides direct voice translation. The pilot will start with Polish interpretation. Once we are satisfied with the quality of interpretation and overall effectiveness of the device, we will move onto Romani and other languages.
• The engagement of Roma women has been discussed with the midwife for vulnerable migrant women who reports a decrease in Roma women referrals. The Maternity Team is reviewing how to improve engagement and communication to Roma women.
• The Maternity Team is scoping the possibility of all-female elective caesarean and sonography lists, as well as the possibility of community sonography within the Mary Potter Community Clinic.
• Our Inclusion Team is implementing a pilot of bi-lingual, all-female antenatal classes for non-English speaking women from April 2024.
• The discharge video transcript is being translated into the top five languages identified by our and Interpreting Team (Polish, Urdu, Arabic, Romanian and Farsi). This will be relaunched in March 2024. The next steps will be to include Romani, Slovak and other languages.
• We are working on Patient Information Leaflets in different languages. We will use the Language Line to translate safe sleeping on discharge information to non-English speaking women. The experiences and importance of understanding this will be shared with the Maternity Teams and closely monitored.
• The Recite function on our website enables all information, including leaflets, to be translated into other languages. It will also read the information aloud in different languages. We have made this feature more prominent on our site.
• A Trust-wide mandatory training video on interpreting and translation services is being produced to raise staff awareness. This will be available from April 2024.

2. Support for the Inclusive Maternity Senior Leadership Roles to challenge behaviours and culture.

You have met the Inclusive Maternity Team, which is leading our work to improve inclusion in Maternity Services. This initiative is a high priority for the organisation and has my personal support, as well as that of the Chairman of the Trust, Nick Carver. The team is working with the Trust’s Equality, Diversity and Inclusion Team and our Chief Nurse. The Team reports directly to the Director of Midwifery and is supported by the Maternity Improvement Programme Board and the Family Health Divisional Leadership Team.

3. Reports of racist and discriminatory behaviour throughout our Maternity Services highlighted in the examples you provided.

I am disappointed to hear that women and families have experienced discriminatory behaviour. This is contrary to our values and beliefs, and I take it very seriously. I would be grateful if you could encourage the women and families concerned to contact our Patient Advice and Liaison Service (PALS) Team (via pals@nuh.nhs.uk) to enable us to investigate the incidents thoroughly and take any appropriate action.

From January 2023 the Maternity Service implemented a two-day cultural competency training course. This training explores assumptions around culture and encourages leaders to understand the importance of inclusion.

The Maternity Service delivers obstetric emergency training (PROMPT) to multi-professional groups. This includes a “psychological safety” workshop to create an open dialogue and to explore concerns about, and raise awareness of, inclusion culture and safety.

The Maternity Service introduced the Integrated Maternity Personalised Annual Care Training study days from January 2023. This is for all midwives and support workers. The training is based around case studies and raises awareness of the different cultures and individual holistic and spiritual needs. This training will be completed by 90% of midwives by July 2024. The learning outcomes are based on Core Competency Framework Version 2 (NHS England, 2023).

The training explores situational awareness and how we accommodate different faith needs. Furthermore, plans are in place to incorporate cultural awareness into the multidisciplinary study days. The training will be evaluated and reviewed in the summer. Any changes will be incorporated before the training is relaunched in September 2024.

Engagement sessions are being planned with sonographers across the Service. The aim of these sessions is to use data to identify ways to highlight the importance of scanning and to improve services for communities which do not engage well with the service.

One outcome of the sessions will enable us to provide a service that can allow children to attend with the woman / birthing partner, and to raise awareness of cultural sensitivity and nuances amongst these communities. We hope this will support better engagement, patient experience and attendance to appointments. The aim is to improve outcomes for communities, where engagement might be hampered by lack of childcare.

4. Behaviour of staff, highlighted by the example given; comments regarding the use of mobile phones by staff; and mothers not being listened to.

Thank you for sharing the concerns raised by a specific service user regarding the behaviours of postnatal Maternity staff. It is upsetting to hear that women and families have reported being subjected to this behaviour. I have arranged for a formal apology to be sent to the family.

The use of telephones is common practice and essential to staff being able to care for women. For example, everyone has a hand held device or telephone to input into Nervecentre, the electronic observation and handover tool. You have identified that this is not clearly understood or communicated to patients and families. This will be addressed with teams.

A golden thread through maternity training is communication and the importance of listening and responding to concerns with compassion. Last year, for example, this was included in the training to 200 midwives within the resuscitation training day. Understandably, you have raised a complaint on a service user’s behalf, which we take very seriously. I have asked the Complaints Team to initiate an investigation through the formal complaint process, subject to the consent of the complainant.

5. Long lengths of time elapsing from concerns raised and the response by the Trust. Resources to support teams to ensure timely investigations and responses.

I extend my apologies to families experiencing long delays as a result of raising concerns. We are committed to addressing issues identified from feedback and incidents so as to prevent harm and distress. We have established a clear framework for resolving complaints and concerns which you are referring to me. In addition, we have put in place sufficient resource and mechanisms to manage these referrals. That said, it has been challenging to identify suitably skilled and experienced external capacity to undertake this work.
To address the case highlighted within your letter, senior colleagues from the Maternity Service have been in contact with the family and a Multi-Disciplinary Team (MDT) birth debrief took place in December 2023.

Our Maternity Patient Experience Matron is undertaking a thematic review of the birth reflection and MDT birth debrief service. This will include a review of waiting list times and resources for discussion at the Independent Maternity Review panel.

When we receive concerns from women and families, we make initial contact with them to agree expectations, time frames and mode of communication. Our aim is to keep in contact while we undertake further investigation. The recently established Maternity Review Process Panel is currently reviewing how we measure and evaluate whether we are meeting the needs of women and families. This work is overseen by The Independent Maternity Review Oversight Group, which I chair.

Thank you again for your continued feedback and for engaging with us on our improvement journey.

Yours sincerely
Anthony May OBE DL
Chief Executive

First Floor, 31 North Street, Chichester, West Sussex, PO19 1LX

19 December 2023

By email only:
Mr Anthony May OBE DL
Chief Executive
Nottingham Hospitals NHS Trust
Trust Headquarters
City Hospital Campus
Hucknall Road
Nottingham
NG5 1PB

Dear Anthony,
Further to my attendance at the Learning and Improvement meetings of 31st August and 14th November 2023 at the Trust, as agreed, I am writing to record the issues raised and discussed at the meetings and our subsequent conversations. I recognise that a significant amount of contact between yourself, myself and Michelle Rhodes as Chief Nurse occurs in between these meetings. I also know that a significant amount of work is put into responding to the issues I raise at and in between these meetings and that families raising concerns do receive responses and some support. Please extend my thanks to everyone who is involved in the ongoing journey of maternity improvement at the Trust. Of note, service users continue to praise the efforts of community maternity staff at the Mary Potter Centre; particularly in their efforts to advocate for them in often very complex situations.

As of today and since June of this year I have referred 35 families to you where families have specifically asked that concerns they have should be shared directly with you as CEO. What has happened to these families covers the full timeframe of the review from 2010 but with a number of the concerns raised being of very recent occurrence.

The issues I raised at the last Learning and Improvement meeting and our conversations/ contact since include the following:

• Translation and Interpretation service provision across maternity care at Nottingham University Hospital NHS Trust remaining very poor with continuing issues of lack of interpretation most evident during hospital care / appointments. For example:
  • Mothers from the Roma community told me that hospital interpretation for Romanian speakers was very poor and that where interpreters were provided they were often male which was not culturally appropriate.
  • Other families have told me, (this needs urgent checking by the Trust) that the discharge information video covering vital issues such as ‘safe sleeping’ for babies that families watch on an ‘IPad’ before discharge is in English only.
  • There are ongoing concerns raised by a number of mothers of their inability to provide informed consent about some clinical procedures because hospital translation services are often so minimal/ non- existent.
     
• Service users across many of Nottingham’s communities continue to report racist and discriminatory behaviour from a range of care givers throughout maternity services. Women and their husbands have reported to me that non- white mothers are spoken to more rudely and in a more dismissive way than their white counterparts. I have now heard this from families from a wide range of backgrounds on countless occasions this year. For example:
  • One mother described a bedsheet ‘being thrown at me’ by a member of staff after she had repeatedly asked for help to change a bloodstained bed;
  • Another who described ‘dirty looks’ because of the way she dressed.
  • Another mother, who had just lost her pregnancy (and whom we have discussed and you are reviewing this case) described a member of staff mimicking her accent, voice and mannerisms. Instead of being reprimanded, other members of staff who the mother believed were senior were laughing at the behaviour of their colleague.
  • The same mother asked for an interpreter prior to an intimate procedure and was told by the Trust employee: ‘I think you understand enough, no need for an interpreter.’
     
• A father, Mr M described the attitude of maternity (postnatal) staff as ‘Get lost! On your bike! Out the door…’ In addition he and others report maternity staff ‘constantly on their phones, more interested in their phones than giving care.’ I think it is important this issue is reviewed by the senior maternity team. I have provided the Trust with further detail of this family who have requested a formal apology for the way they were treated by maternity services in August 2023.
   
• Mothers have told me of staff not listening to mothers both in the antenatal and postnatal periods when they describe feeling significantly unwell or in need of assistance. You will be aware of the case of Mrs B who collapsed and subsequently required care in ITU this year, having tried repeatedly to raise concerns with staff. She had previously told staff she felt hot, dizzy and unwell and was told it was the hot weather. Mrs B has asked that I follow up on a formal complaint with the Trust as she feels unable to do this herself. This process is underway.
   
• Long lengths of time elapsing from concerns being raised by families to receiving any kind of response from the Trust. This includes family requests for information about their case (for example what has happened to their baby) going unanswered. As an example, we have both had significant involvement in the case of baby S whose parents have waited a year to receive answers about their case. This meeting is now arranged but appears to have been lost ‘in the system’ until I raised the case with you directly.

We have discussed the work of the Inclusivity Maternity Taskforce, (IMT) set up since the April 2023 Learning and Improvement Meeting. Whilst I look forward to hearing of further progress from their work I raised concerns that the leaders of this work must have the support, influencing skills and ‘seniority’ to deal with what now appears to be a long term and very entrenched problem of discrimination and lack of inclusion in the delivery of maternity care at the Trust. I am pleased that this work is being supported and led personally by you as CEO, Nick Carver, Chair and the Board. You have explained to me that your support will extend beyond maternity to early pregnancy care and in all likelihood beyond women’s health to other areas of the Trust. We agree it is essential, that the IMT must have the resource and support to deliver upon a very challenging agenda across the Trust.

We have also discussed the resources made available to clinical and governance teams to ensure appropriate and timely enquiry into and investigation of clinical incidents and concerns raised by families. The case above of Mr and Mrs S who have waited a year to receive information on the case of their baby is not the only case we have discussed. We have agreed it is important that the Trust ensures maternity (and any other teams) needing to investigate clinical or family concerns are appropriately resourced to ensure that these concerns are looked into and responded to in an appropriate timeframe. We both agree that families should not have to repeatedly follow up with the Trust, searching for answers which only compounds the distress they are, in all likelihood already experiencing.

Yours sincerely,
Donna Ockenden

Copy:
Duncan Burton, Deputy CNO, NHS England, Chair, Learning and Improvement Meeting

September 2023

We have responded to Donna Ockenden’s letters of April and August 2023 to outline positive action taken against the feedback that has been provided to the Trust.  You can read the full response from Anthony May our Chief Executive in the letter below:

 

Dear Donna,

Re: Independent Maternity Review – Nottingham University Hospitals NHS Trust
Thank you for meeting with us on 14 April and 21 June, and for your subsequent follow up letters dated 20 April, and 8 August 2023. In our most recent meeting, we promised that we would formally write to outline how we have responded to the points you raised in the two letters above, both of which are published on our website (20 April 2023, and 8 August 2023). The responses below also reflect the verbal feedback provided by Michelle Rhodes our Chief Nurse in our meeting on Thursday 31 August.

As always, we welcome the opportunity to hear your feedback on a regular basis, as it allows us to take action. We also are pleased to have been able to use the meetings to update you verbally on the work of the Maternity Improvement Programme at NUH, including on some of the feedback detailed below.

Points addressed in the correspondence dated 20 April 2023
You expressed to us that the feedback you had received from local Black and Asian women was that mistrust of the Trust has deepened and that our communication and relationships with them have progressively worsened. This included language and communication’ failures with women saying they did not feel heard or seen:

• Concerns from maternity staff of a proposal to reduce Urdu language appointments accompanied by an interpreter from 30 minutes to 20 minutes.
• That women had raised with you a lack of interpreting services within the Trust leading to women for whom English is not their spoken language having to make decisions without informed consent.
• A lack of translated written materials into languages such as Urdu, which was leading impacted women’s ability to make informed choices about their care.

In the letter, you also described ‘a failure to appreciate cultural sensitivities’ including occasions when a female sonographer has not been available for the care of Muslim women who had requested one.

We have thanked you for this important feedback and taken significant action since the meeting on 14 April to address the issues identified. Colleagues in our Transformation team presented some of the activity to you in our subsequent meetings on 21 June and 31 August. Progress made since April includes:
• A new taskforce of midwives, doctors, researchers, advocates and representatives from Black, Asian and minority ethnic staff and families has been immediately established.
• The proposed change to the length of appointments was not introduced.
• Information on the maternity pages of our website is accessible and available in different languages.
• Letters inviting women for scans now include the choice of a female sonographer if preferred.
• Forthcoming events in the service with a focus on inclusion include a ‘Who’s Shoes’ learning event aimed at black and ethnic minority service users in maternity, and a Maternity Staff Summit in October as a celebration of Black History Month.
• Our lead midwives are representatives on the local LMNS Maternity Interpreting Services working group.
• We are piloting a 24-hour Languages on Demand Video Interpreting service in our labour suites from 11 September 2023, which will allow live consultations or pre-booked appointments. This service includes Urdu as one of the languages.

Points addressed in the correspondence dated 8 August 2023
You told us that women told you they were still told to ‘break their fast’ for some blood tests without flexibility for early or later blood tests during the month of Ramadan.

This feedback has been shared with our anti-natal services Matron, and various actions are being taken to address the issue, including; engagement with a local Muslim women’s group for education and awareness; a date has been set for January 2024 in order for us to raise awareness with staff and to plan proactive communication with women on this issue; and we are planning a visit to Bradford’s anti-natal services to learn from their approach.

You shared with us feedback that women you had spoken to had repeatedly told they are not in labour ‘it’s Braxton Hicks’, when contacting the unit, and that other women are told they could not be in labour and to stay at home ‘if they can ‘talk on the phone.’ You identified a theme of women not being believed that they were in labour.

This information has been shared with the matron and managers for Maternity and Labour (MAL) and has been added to the agenda for the next MAL team meeting for further discussion and awareness. We are improving our communications channels within the service for sharing learning and feedback such as this, including a new MAL email list including CMW, NHSP and triage staff, as well as a new learning whiteboard for Maternity and Labour. We are also working to separate the latent phase of labour guideline for staff from the overall intrapartum guideline to make it easier of staff to access the right information. We have also checked our complaints records for any additional intelligence or learning, although it has not been identified as a theme in our records.

You identified “repeated examples of manual removal of placentas’ being undertaken without appropriate anaesthesia in a labour ward room rather than in a theatre, often with only gas and air.” Our maternity guideline sets out that manual removal of placentas should be undertaken in theatre with consent and adequate analgesia. We have reviewed all of these procedures which have been recorded on Badgernet since the beginning of 2023, and 97.5% comply with the guidance.

The cases that were not managed in accordance with guidance are being managed as incidents to understand what happened and to identify opportunities for learning.
Parents had fed back to you that the maternity team were using genetic testing as a ‘first line’ of enquiry, before any governance investigation or enquiry following a baby being born in unexpectedly poor condition.

We have investigated this feedback to better understand any underlying concerns. For diagnosis of Hypoxic-ischemic encephalopathy (HIE), we follow standard criteria which are established nationally, and are in our neonatal HIE guidelines.

Genetic testing is not done routinely at NUH, and where there is clinical rationale to follow a HIE test, it must be discussed with the parents first. Genetic testing is only carried out in circumstances where the clinical presentation doesn’t quite fit and there is a possibility of other factors (family history for example), or no discernible underlying cause for hypoxia. Of more than 200 referrals for R14, there are only two instances where HIE is mentioned, and if a baby was referred for testing with just HIE, the guidance if for the test to be rejected.

R14 genetic tests are only carried out under the direction of the genetics expertise.
Parents reported to you that they had been told by the maternity team that their notes had been ‘lost’ by the Trust but the Review team have them (electronically) meaning they cannot be lost.

We have requested more specific information on these cases so that we can review and respond on the individuals involved.

We hope that the above responses given you assurance that we are taking the feedback that we receive from your team, mothers, and our colleagues seriously, and that we remain committed to taking action to resolve issues where they are identified.

You will also be aware that since we met, the CQC have published their latest reports for NUH, which has upgraded maternity services at City Hospitals and Queen’s Medical Centre to Requires Improvement from Inadequate. We know that we have improvements to make but are pleased that the regulator has recognised the progress that has bene made so far.
In their report, the CQC found that “Staff in both maternity services were kind and understood the personal, cultural, religious, and social needs of each person and showed understanding and a non-judgmental attitude when caring for or discussing people with mental health needs.”
Nottingham University Hospitals remains fully committed to the Independent Maternity Review, and we look forward to meeting with you again shortly.

Yours sincerely

Anthony May OBE DL
Chief Executive