University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely.
It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be.
Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services.
What did the CQC inspectors see?
The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage.
During the inspection on March 7th, there were 12 patients waiting for triage.
Of those, five pregnant women waited longer than the expected 30 minutes to be seen, with delays up to 55 minutes.
Information relating to triage patients waiting for urgent care was not presented clearly, did not specify where a patient was, and if they had been seen by a doctor or midwife.
Staff failed to update a whiteboard with a list of patients waiting for triage which inspectors said led to confusion of who what patients were still waiting.
One incident from the Royal Stoke University Hospital in February 2022 showed a delay in triage ended with an intrauterine death for one patient.
In June 2022, another patient delivered a still-born baby, but a review of their triage assessment times showed the parent had waited nearly an hour to be seen.
The CQC said between October and December last year, nearly a quarter of admissions did not have triage times recorded which could have put patients at increased harm, after looking at previous reports done by the trust.
On the day of the inspection, the CQC found 7 of the 18 pregnant women scheduled for an induction had been delayed from the previous day.
One patient, who was recognised as high-risk, had their induction delayed five days in a row.
If the trust fails to improve its maternity services by the end of June, further action could be taken against University Hospitals of North Midlands NHS Trust.
Ann-Marie Riley, Chief Nurse at the trust, told ITV News Central, “Following an inspection by the CQC to UHNM maternity services on 7 March, the Trust received feedback on the day and formal notification of some concerns in relation to triage in the Maternity Assessment Unit and delays to induction of labour.
"We recognised the areas of concern highlighted by the CQC and already had a programme of improvement work in relation to the induction of labour underway.
"We also took immediate action to address the concerns regarding the Maternity Assessment Unit," Ms Riley added.
"The CQC has acknowledged the changes made since their visit and the positive impact they have clearly had.
"We are continuing to work hard to not only implement further improvements but to ensure they become embedded.
The trust says it hopes to deliver the highest standard of care by implementing new systems and ensuring they remain in place.
Ms Riley said, "As soon as the full report is available it will be published in full along with the actions we are taking to address any further comments and suggestions made by the CQC inspection team."
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