The safety of mothers and babies at the foundation’s Furness General Hospital remains at “significant risk”, according to a new independent review commissioned by foundation trust regulator Monitor.
The review team, from St Mary’s Hospital, Manchester, also warned that the absence of “robust systems and leadership” suggested there might also be risks at UHMB’s Royal Lancaster Infirmary.
Monitor commissioned the review in November 2011, after a surprise Care Quality Commission in June led to a damning report on maternity services at the Furness site.
On the strength of their findings – and those of two other reviews Monitor commissioned at the same time – the regulator yesterday stepped in to install a new chair at the Cumbrian foundation.
The Maternity review, published this afternoon, states: “Overall there remain significant risks for the safety of mothers and babies particularly at Furness General Hospital but the lack of robust systems and leadership overall would indicate there is potential risk at the Royal Lancaster Infirmary too.”
The review team concluded that while the trust had developed “a number of action plans in response to the various incidents, reports and reviews”, there was “a lack of overarching strategy and overall leadership”.
Both of these would be needed “as a minimum” to develop a baseline improvement strategy, monitor it, and to provide the UHMB board that maternity and neonatal services were safe, they said.
They found both the managerial and professional leadership of UHMB’s maternity services to be “of major concern”. Despite the recent number of serious untoward incidents at the FGH site they found “no senior presence” there above the level of midwifery matron. The foundation’s executive team and divisional management team were both based at another hospital.
Medical and midwifery teams worked separately and blamed each other for the “lack of cohesion”. The team also reported a lack of role models in the service, finding “a number of professionals who had the desire to provide an excellent service, but who did not have the requisite experience or guidance to enable them to do so”.
It recommended UHMB take “immediate action” to install a clinically qualified executive director full time at the FGH site.
At the hospital’s neonatal unit – which has six special care level cots – they found “no systems in place for nurses to take meal breaks without leaving just one member of staff on the ward”.
Some staff worked more than 12 hours without a break, and at the time of the review a third of nurses on the unit were absent due to sickness. The nurses they interviewed “appeared to be very conscientious but were extremely concerned about the situation”.
The team reported that immediate action was needed to ensure all neonatal nurses were able to take appropriate breaks.
7 February 2011