Maternity services at University Hospitals of Morecambe Bay FT are still failing to meet essential safety standards nearly three years after failings in care contributed to the death of a newborn baby.
The Care Quality Commission ordered urgent improvements after unannounced inspections in July this year identified “major concerns” with staffing levels, risk management and outdated facilities.
Inspectors visited maternity services at three hospitals including Furness General, where baby Joshua Titcombe died from a lung infection in October 2008.
The visits came a month after the coroner who looked into the child’s death delivered a damning verdict, criticising midwives for not spotting signs of infection and issuing an official notice to the trust to address care failures.
The CQC, which carried out joint inspections with the Nursing and Midwifery Council, found the trust had failed to meet six essential standards in the most recent spot checks.
Inspectors said patients may have been put at risk and care delayed due to the lack of a back-up out-of-hours emergency team.
They also criticised the “outdated care environment” and the systems in place to reduce risks to mothers and babies.
“There are risk registers in place but risk ratings are not consistently applied, nor are concerns always escalated to the most appropriate management level,” said the CQC.
The CQC also found fault with aspects of record-keeping, hygiene and infection control and failings when it came to respecting and involving patients.
“Although many of the women we spoke to were positive about the care they receive, our inspectors found that the trust needed to do more to ensure that women and babies receive safe care,” said Sue McMillan, regional director for the CQC in the North West.
The trust said it had made “vast improvements” since the Titcombe case, which prompted a wide-ranging review of maternity services.
It said it was working on plans for a brand new maternity unit and a second out-of-hours team would be in place this money and it had acted immediately to address the cleanliness and record-keeping issues raised by the CQC.
The trust accepted the failures in risk management identified by the CQC were “unacceptable”.
“A review of the incident reporting system and all the risks identified for these areas has begun and an action plan has been submitted to the CQC to ensure that this situation is rectified and not repeated,” said a statement.
Jackie Holt, the trust’s director of nursing and modernisation, said the trust was “moving in the right direction”.
“However, we are by no means complacent and these improvements are the next step in our journey to improve the quality of care,” she added.
The NMC has completed a separate investigation into supervision for midwives at the trust with a report due in early October.
An NMC spokeswoman said the report was currently with the trust and she could not comment further on the findings.