Broomfield Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During the assessment we found that not all risk assessments were documented and not all women and birthing people had their medical care reassessed in accordance with national guidance. The trust could not always be assured that staff always recognised risk or took the necessary action to mitigate those risks. The lack of processes placed women, birthing people and babies at risk of harm. We were told staff did not always have time to complete incident reports and these were often completed retrospectively by leaders. The trust did not always ensure learning and prompt actions were completed after incidents had been reported. At the time of assessment, the trust had 124 outstanding maternity action plans that dated back to 2020. During the assessment we observed how capacity and flow issues impacted on the delivery of care which fell short of national standards and trust policy. We reviewed 10 maternity records and found 2 care records had the wrong person’s clinical notes filed within them. The trust’s lack of record standardisation and effective auditing processes increased the risk of administration and clerical errors. We observed incorrect storage of medication and milk products that were not in line with trust policy or manufacturers guidance. Staff on the postnatal ward did not have an updated awareness of baby abduction drills and procedures. The service did not always have the necessary facilities and adequate equipment to meet the needs of women and birthing people, and families. We identified 1 area being used as a waiting room that was not suitable or safe for women and birthing people. We observed a lack of adherence to national triage processes on DAU, such as poor record keeping and a lack of monitoring of incoming calls and repeated calls into the triage phonelines. This meant that repeat callers may be missed.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

During the assessment we spoke to 10 women, birthing people, and their families at Broomfield maternity unit. People felt able to raise concerns and told us that they were mostly dealt with promptly by staff. Patient survey data from 2023, showed that 86% of birthing people felt if they raised concerns during antenatal care, that their concerns were taken seriously. As part of the assessment, we reviewed 24 complaints that had been received between March 2023 and February 2024. The trust had recognised themes from complaints received from women, birthing people, and their families. These related to clinical care, staff behaviour, care delays, misdiagnosis, and issues around their birth experience. We spoke to women and birthing people in DAU who were in the unit for assessment and medical review. Some people told us that during early pregnancy relevant medical history and results from blood test had been missed. However, consultants had recognised the error and were open and honest with the birthing mother and had taken steps to improve their care moving forward.

Some staff told us they were not consistently made aware of learning from incidents and that information was mainly shared via word of mouth in the staff rooms. The trust used “Hot Topic” posters as a platform to share learning, but staff felt it would be beneficial to have more formal learning from incidents feedback shared with them. Leaders recognised that sharing learning via email was not the only way to communicate with staff and that different formats could be used. The trust had recently appointed a communications manager to improve shared learning by using multiple platforms to share information. Leaders informed us that they held governance meetings 5 days a week to discuss incident themes and identify learning. It was not clear how these discussions were cascaded down to the maternity teams. All staff were aware of the Risk Management Information System however multiple staff told us that they often did not report incidents as they were concerned about other colleagues getting in trouble. Staff told us actions identified after an incident investigation using the Perinatal Mortality Review Tool (PMRT) framework were not always completed. Staff felt there was a lack of assurance and oversight when implementing these actions. Leaders told us they had 124 outstanding maternity incident action plans, dating back to September 2020. Actions related to failings in care, identified risks and recommendations for lessons learnt. This delay in completing actions was not in line with the trusts policies and was putting women, birthing people, and babies at risk. Leaders told us that the remaining incident action plans had been assessed and were being completed based on their risk priority. Leaders had a plan to review and complete the outstanding actions by September 2024 but this process was on going. Staff told us they had to suspend 11 investigations due to patients care records not being completed correctly or documents missing from records.

The service had policies in place to guide and direct staff to raise concerns, this included bank, agency, and volunteer staff. We found reported incidents were not always investigated in line with policy timeframes. For example, we reviewed 3 serious incident reports which occurred over 4 months ago and were not investigated within the timeframe set out in the policy. We also identified that 2 of the incidents were not referenced in the trusts action plan for divisional oversight. Delays in completing incident investigations may place women, birthing people and babies at risk of harm. We reviewed 19 PMRTs, 3 serious incident reports and 5 reports from the NHS Strategic Executive Information System (StEIS) and the National Reporting and Learning System (NRLS) for the last 12 months. We identified that not all incidents and subsequent recommendation and actions reported through these external systems had been included within the trusts outstanding action plan log. This meant that we could not be assured that there was sufficient oversight of recommendations and learning from incidents. It was identified during the March 2024 public board meeting that the Broomfield maternity services had 7 open serious incident investigations, 4 of which were under review from Maternity and Newborn Safety Investigations (MNSI). In January 2024 there were 106 overdue maternity incidents at the Broomfield site. Leaders told us that they were addressing this backlog, however at the time of assessment there were still 672 individual actions outstanding, of which, 163 directly related to shared learning from incidents. The failure to identify, learn and act from incidents in line with policy could lead to further risk and harm to women, birthing people and their babies being cared for by Broomfield maternity services.

Women and birthing people in DAU told us that they had experienced a smooth transition from community services to hospital care. Women and families felt they had access to all the relevant information including maternity packs and QR codes for information. Women and birthing people who were booked in for elective c-sections (ECS) were clerked in through the antenatal clinic. This waiting area did not have clinical oversight by maternity staff. Women and birthing people told us they could spend many hours in this area waiting for their ECS with minimal clinical observations being taken and welfare checks. People in this area told us they felt vulnerable and isolated during their care journey. We immediately raised our concerns with leaders. The trust took action to relocate the ECS waiting area to within the labour ward. This area was more comfortable and had clinical oversight from maternity staff. On reviewing the trusts complaints received from March 2023 to February 2024 there had been concerns raised around care journey experiences and delays in treatment.

Some staff told us that flow through the department was a known issue to leaders. During the assessment, there was a lack of available beds which was highlighted during the leader’s daily safety huddle meeting. At the time of the assessment, capacity issues on the labour and postnatal ward led to induction of labour (IOL) being postponed. Leaders told us the department was extremely busy leading up to the bank holiday weekend. The multi-disciplinary team had facilitated an extra ECS list to manage the additional demand. Some midwifery staff we spoke to felt that consultants often prioritised elective c-sections over risk based IOL. This may place women, birthing people at risk of harm as their needs may not be met in a timely way. Some staff told us there was pressure to discharge women and birthing people home and they wished they could keep people longer on the wards. Leaders told us that in times of service pressures they would utilise the other MSE maternity sites if possible. However, staff told us that sometimes people were reluctant to have care transferred to another MSE site, meaning the postponement would go ahead. During our assessment we witnessed a busy postnatal ward with women, birthing people and their babies returning for appointments and assessments. Staff told us they had seen an increase in neonatal readmissions, babies with weight loss, jaundice and women and birthing people with infections. The postnatal readmission pathway for babies had been identified as a risk for the last 3 Women’s Health Governance Meetings and had been on the trust risk register since August2023. The service had started a workstream to look at reducing baby readmission numbers, however at time of assessment this was at an early stage.

The Mid and South Essex Maternity and Neonatal Voices Partnership (MNVP) is a team of women, birthing people and their families, commissioners, and providers (midwives and doctors) working together to review and contribute to the development of local maternity care. The MNVP welcomes feedback on maternity service experience; it is used to make direct improvements to local services that are offered. As part of our assessment, we spoke with MNVP team to understand their partnership working with Broomfield. The MNVP told us they held quarterly meetings with the service where they escalate feedback from women and birthing people to maternity leads. A big focus had been on supporting the diverse communities who use the service. The MNVP worked with ethnic community leads to shape improvements for maternity services across MSE. The MNVP told us the trust included them in quality projects, for example the maternity antenatal information booklet was co-produced with the trust that covers all ethnicities. MNVP said there was a piece of work underway on pre-conception health to provide women and birthing people with accessible information to best support them to prepare for their pregnancy journey. They told us they had a good working relationship with the Heads of Midwifery and Director of Midwifery and felt this collaboration was having a positive impact on women and birthing people’s pregnancy experience.

The service had policies, guidance, and standard operating procedures in place. However, the trust acknowledged that there were 22 out of date documents which were all under active review at time of assessment. We were not assured the trust had all the relevant up to date guidance embedded in their care delivery putting women, birthing people and babies at risk of harm. As part of our assessment, we reviewed the trusts submissions to their clinical indicator dashboard which showed Broomfield between May 2023 and September 2023 was above the national average for neonatal deaths for this timeframe. On requesting and reviewing recent service data, it was highlighted there had been a cluster of neonatal deaths between February and March 2024. The trust told us they underwent an immediate review of the care pathways of the neonatal deaths, but these were not completed at the time of the assessment. PMRT’s identified staff did not always risk assess women and birthing people, act on presenting risk or handover concerns effectively to ensure appropriate care was provided. We escalated our concerns to the trust who are still investigating the recent cases. Care pathways processes were not always followed. We saw evidence of ongoing delays to care, delays in IOL, artificial rupture of membranes (ARM) and augmentation of labour. Following our concerns the trust took steps to improve the capacity issues and transferred 1 of their elective c-section lists to another MSE site, therefore reducing the need to delay procedures at Broomfield and freeing up more space and staff. The trust told us they would continue to monitor the impact and care outcomes of this action by carrying out regular audits.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Within the DAU there were printed patient care leaflets available including advice on fetal monitoring, infant feeding, and induction of labour. These advisory leaflets also outlined signs and symptoms to be aware of and what to expect during treatments. People told us that staff had explained all assessments and treatments prior to commencement. Information was shared in an accessible format, and they were signposted for additional support if needed. People we spoke to on DAU/ triage told us they felt able to raise concerns and felt these were dealt with promptly by staff on duty. People told us that staff had been open and honest when an identified risk had been missed in their care journey and the appropriate verbal duty of candour had been completed.

On the day of assessment there was not always a team approach to care delivery. Some midwifery staff told us they felt consultants gave treatment priority to elective c-section patients over those waiting for medical induction of IOL. Midwifery staff felt consultants did not always assess the potential risks involved with delaying IOL processes due to capacity restraints. Staff told us that they did not always get the time during a night shift to complete the necessary safeguarding referrals but made sure these were handed over to the day staff to complete. Leaders told us they held twice daily huddle meetings at 9.30am and 4pm across all 3 sites to discuss risk, staffing, acuity, and neonate admissions. It was unclear how information discussed at these meetings was shared with staff on duty. Some staff told us they were not clear on what constituted a maternity red flag. A midwifery red flag event is a warning sign that something may be wrong with midwifery staffing. If a midwifery red flag event occurs, the midwife in charge of the service should be notified. The midwife in charge should determine whether midwifery staffing is the cause, and the action that is needed. We were not assured the trust had full insight into delays in care. Staff told us the trust used “Hot Topic” posters to communicate incident outcomes. However, the posters displayed in DAU were 2 years old, therefore we were not assured staff were always aware of lessons learnt from recent incidents. Staff told us they had access to the trusts digital application to keep them up to date with changes in policies and procedures and were able to tell us the top 3 risks for maternity services. Staff we spoke to on the postnatal ward were not aware of the correct processes for alerting security staff of a baby abduction. Following the assessment, the trust took action to ensure staff had refresher baby abduction training and ensured all staff were aware of the correct escalation procedure.

The service reported they used a nationally recognised maternity triage system when assessing the clinical needs of women and birthing people. However, there was a lack of dedicated triage space, and they did not always use the risk assessment tool fully. For example, not all records reviewed had documented pregnancy history, fetal movements or presenting complaint. Furthermore, there was no oversight on what clinical grade of staff had answered the phonelines and there was no monitoring for dropped or repeated calls. This meant there was a risk of women and birthing people not receiving appropriate and timely response to their calls. Following our assessment the service took action to ensure all calls were logged and reflected in audit data. In addition to this, the trust allocated a dedicated area with a nominated midwife to answer triage telephone calls in line with the national recognised triage system recommendations. PMRT and Healthcare Safety Investigation Branch (HSIB) reports reviewed showed the trust did not always follow national guidance in relation to identifying fetal growth restricted babies and they were not fully compliant with Saving Babies lives care bundle v3 (published May 2023). At times the service failed to identify risk factors and make the necessary referrals for genetic screening to identify the risk of birth defects. This meant women and birthing people were not always able to make informed decisions about their care. The service took action to implement a formal assessment process to clinically prioritise and record women and birthing people who had their IOL delayed. We found care records were not always comprehensive, staff told us they could not access all relevant information easily due to multiple care booklets; loose document sheets and additional forms being stapled in care records.

Women, birthing people, and their families overall felt the departments were suitable to meet their needs. However, women, birthing people and their families seated in the elective c-section waiting area had no direct access to clinical staff and were told if they needed assistance to knock on an office door to get help from administration staff. The seating area had limited facilities, uncomfortable chairs and no direct visibility by midwifery staff. This area was not suitable or safe which put women and birthing people and babies at risk. We escalated our concerns to leaders and following the assessment the trust relocated women, birthing people and their families to another area within the labour ward. This area was more comfortable and private where women and birthing people would have continuous clinical oversight by maternity staff.

Some staff told us there had been several births in the triage area. They were concerned that when this occurred midwifery staff were then taken away from answering the triage telephone calls and attending to other women and birthing people in the unit. Staff also felt there was a lack of dignity and privacy for women and birthing people delivering in the triage/ DAU area in curtained bays. Senior leaders acknowledged that at times babies may be born in triage/DAU area, but this was an exception. However, evidence reviewed showed that some women and birthing people had been in active labour for hours whilst on DAU. Staff on DAU were concerned that women and birthing people were being diverted to triage bays due to lack of capacity on labour ward. Staff felt this made the environment unsafe and it restricted space and took midwifes away from other women and birthing people. Leaders also told us that neonatal resuscitation equipment was not required in DAU/triage as the neonatal team would bring their own. This did not align with best practice, therefore potentially putting babies at risk of harm through lack of specific equipment for resuscitation. Staff in DAU also told us the triage waiting room was used for shift handovers twice a day. This meant that any women, birthing people and their families would have to vacate the area and stand outside the room until handover was finished. There was a risk to patient’s confidentiality as information could be heard in the corridor despite the door being closed. Staff told us they had no other option as space was limited.

The design of the environment followed national guidance. The unit was secure with a monitored and locked entry and exit system to the different units and reception areas. During the assessment we checked 30 pieces of equipment and found 21 items out of service date. In response to this the service carried out an audit and found 96 pieces of equipment in the department overdue service dates. Leaders reassured us all equipment would be serviced and inspected once a month by the clinical leads. We found call bells were accessible, and staff mostly responded quickly on the DAU and labour ward. We found only one set of ligature cutters available to staff across the whole department. Signage to their location was contradictory and could cause confusion and delay in an emergency. After assessment, the service sourced additional ligature cutters and their location was shared with all staff to mitigate this identified risk. During assessment we raised concerns that resuscitaire were not present in all birthing rooms. A resuscitaire is a stand-alone piece of equipment that is used during delivery. It combines an effective warming therapy platform with the components needed for clinical emergencies and resuscitation of a newborn. Availability of neonate resuscitation equipment had been highlighted to the Trust in December 2023 following a (HSIB) report. It was recommended the Trust develop a process which ensured all equipment that may be required was immediately accessible and that clinicians and staff were familiar with the location of this equipment. During assessment we did not see evidence this recommendation had been actioned. We observed that not all emergency equipment compliance checks had been completed correctly. Consumables and lifesaving equipment had been marked as checked but were out of date. This meant vital medical equipment might be unsafe to be used during an emergency, putting women, birthing people and babies at risk.

There was not an effective audit system in place to monitor the servicing of equipment used within the maternity unit. Department leads were unsure as to who was responsible to ensure all medical equipment and facilities were safe and fit for purpose. During the assessment we also identified 2 cardiotocograph (CTG) machines that were near to expiry dates. CTG machines are used to monitor a baby’s heart rate and woman, birthing persons contractions during pregnancy. It was not clear that staff had measures in place to ensure the CTG machines would be replaced once the expiry date had been met. Following our assessment the service gave immediate reassurances that this equipment would be serviced. Leaders told us staff would receive refresher training in the correct processes for carrying out equipment checks.

During the assessment we spoke to 10 women, birthing people, and their families. They told us that staff were kind, caring and attentive to their needs. For example, making sure rooms and beds were comfortable and that call bells were accessible. The service supported partners and families during their loved one’s care journey and explained treatments and procedures. The staff gave support to women, birthing people who were anxious or had additional needs. Staff were reported as being friendly and approachable and at times went above and beyond to deliver truly holistic care for women and birthing people attending the unit. People told us the departments were busy but felt staff were doing their best in the circumstances. For example, staff would make sure all women and birthing people were welcomed into the unit and people were told what to expect and timeframes for treatment were outlined if the department was busy. We spoke to women and birthing people undergoing induction of labour procedures, some of whom had had procedures delayed, they told us they felt staffing levels were adequate. Women and birthing people also told us they used the call bells if needed assistance and staff responded when available.

Some staff in DAU/triage told us at times there was not always enough staff and midwifery staff would be reallocated to other wards from DAU/triage if other departments were short staffed. Some staff raised concerns over the skill mix of staff on postnatal ward and felt at times it was unsafe. Some staff told us they often didn’t get breaks or finish on time due to units being busy and handovers being delayed. Staff told us that they frequently had to care for labouring women and birthing people in DAU due to lack of capacity on the labour ward. Evidence from incident reports we reviewed substantiated this. Some staff said that the overall working culture was not always positive and there had been a blame culture within the department. Some staff told us that they had witnessed or been a victim of bullying within the departments and had experienced an unfair distribution of workloads. Staff felt the culture had been improving due to the employment of external staff. Staff told us that the 2-year bereavement pilot that offered tailored psychological support was coming to an end due to funding no longer being available. Staff felt that without this speciality job role, women, birthing people, and their families would be at an increased risk of long-term psychological harm. Staff told us they had access to a digital learning platform that contained all training courses and staff were given protected time to carry out all mandatory training modules. Staff told us they also received yearly appraisals and carried out their mandatory training. However, yearly appraisal compliance across Broomfield was the lowest compared to the other MSE sites, sitting at 70.86% at the time of assessment against a target 90%.

As part of the assessment, we visited DAU/triage, theatres, labour, and postnatal wards. At the time of the assessment, DAU had 10 inpatients, 6 people were receiving inductions of labour and 4 were inpatients awaiting clinical decisions. The reception area was staffed by midwifes and a ward clerk if one was on duty. This area was the hub for incoming triage calls, mothers and birthing people arriving for appointments and for inpatients in the unit. We observed staff were busy managing clinical assessments, answering call bells and phone calls. Evidence we reviewed from HSIB reports and complaints, showed people had raised concerns of care delays due to busy departments and overworked staff. This concern was also highlighted during the service’s daily maternity safety huddles from January 2024 to March 2024. Delays or failure to treatment or procedure had been raised by leaders as a concern during these meetings. In DAU/triage there was a lack of confidentiality around the reception area, women and birthing people were being openly discussed by staff and phone calls could be overheard. During our observation on the postnatal ward, we saw a busy unit with inpatients and women, birthing people and their babies arriving for appointments. There was limited working space to review care records for staff and consultants with some documents being left unattended on the records trolley.

During the assessment we identified gaps in training drills and simulations. The trust confirmed pool evacuation drills were scheduled to take place in September 2023, but this had been cancelled and not rescheduled. We were not assured the service had followed their own policy to accommodate live drills and simulations 1 to 2 times a month across MSE sites. This inconsistency in training put women and birthing people at risk of harm. Following the assessment these evacuation drills were carried out. The service monitored staffing levels twice daily in addition to activity and acuity to ensure safety. The service used a live acuity tool to establish the correct safe staffing levels in every department. The vacancy rate at Broomfield Hospital had improved since the last inspection, the vacancy rate was 17% at the time of the last inspection. The service published their Maternity Safer Staffing and Workforce Planning report in August 2023 which highlighted that the maternity vacancy rate was 13.4%. Leaders recognised that more work was required to reach their target of 11.5% across MSE. As part of the trusts ongoing recruitment and retention plans, they offered midwifery apprenticeships as development for existing staff which started in September 2023 with 8 funded posts. International recruitment and return to practice programmes had also been used to improve staffing numbers. The trusts maternity services worked in partnership with a local university to accommodate academic placements for midwifery students. The service had an annual mandatory training programme for maternity staff that consisted of 30 hours of maternity specific training and 7.5 hours for the trust statutory training. Students and bank staff were also required to complete the core mandatory training and statutory training modules.

Domestic staff worked on the department every day and the environment and equipment appeared clean. Domestic staff told us they felt part of a wider maternity team and understood how important their role was in keeping women, birthing people and babies safe. Staff told us they had regular cleaning schedules that were kept up to date and they had access to personal protection equipment and wash facilities. Staff told us there had been an increase in women, birthing people, and neonatal readmissions back into transitional care on the postnatal ward. Evidence showed they were mainly returning with weight loss, jaundice, and maternal infections. Staff reported TC beds would sometimes be used to accommodate overspill from postnatal ward, which they felt impacted on the availability of TC for neonatal and maternal admission. However, TC could be accommodated throughout postal ward depending on qualified staff availability. This practice was not in line with the services policy and was putting babies at increased risk of infection. Leaders told us they had an external contractor commissioned for legionella testing of the water supply. Legionnaires' disease is a lung infection you can get from inhaling contaminated droplets of water from showers or bathtubs. It's uncommon but it can be very serious. The service gave assurances they were fully compliant with required testing and monitoring of all the wash facilities within the department.

Between April 2023 and March 2024, 260 babies were readmitted to postnatal ward for additional support with feeding, phototherapy, and infections. National guidance around baby readmissions states “The number of unexpected admissions of term babies is seen as a proxy indicator that harm may have been caused at some point along the maternity or neonatal pathway”. The service had acknowledged there had been a steady increase in readmissions of babies with an 81% increase from 2021. Transitional care was a 4 bedded bay area within the postnatal ward with no isolation facilities. This meant that newborn babies were being placed with others readmitted from the community, this increased the risk of infection transmission. Current processes in place did not protect women, birthing people and their babies from risk of infection. Birthing pool guidelines were not available for staff as they were under review. Therefore, staff did not have guidance on correct pool decontamination processes, leaving women and birthing people and babies at risk of harm. DAU/triage had a shared kitchen that was used by both staff and inpatients. On assessment we identified the fridge that was used to store food had been out of temperature range on 20 occasions in March 2024 and staff had not reported this. This posed a potential risk of food poisoning to staff, mothers, birthing people, and their families. This was escalated to the nurse in charge who was unaware the kitchen was being used by patients and had no oversight on the fridge’s compliance. Following our concerns the fridge was decommissioned and all food products were disposed of.

Leaders and staff on the postnatal and labour ward told us they had ongoing issues with maintaining the correct temperatures in the treatment rooms and fridges used to store medicines for the department. Some medicines needed to be stored at a certain temperature as outlined by the manufacture’s guidance. Failure to do so could impact the shelf life and the medicine’s effectiveness. Staff told us they had repeatedly reported high treatment room temperatures to estate and pharmacy leaders but there had been limited action. The trust had a policy in place which outlined the safe storage of medicine, but this was not being followed. We raised this as a concern and the service carried out an immediate review, removed any unsafe medicines and altered the shelf life on those remaining. Staff told us that the fluctuating fridge temperatures were due to fridges being continuously opened and stated that temperatures were checked and recorded once a day. There was no clear guidance for staff to escalate unsafe fridge temperatures and they were unclear of who was responsible for monitoring the fridge temperatures. Following the assessment, all fridges were checked and replaced where necessary. Communication was also sent to staff highlighting the correct procedures to follow when treatment rooms and fridges were out of temperature ranges.

In all areas sharps bins were mostly labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins. During the assessment, we reviewed stock levels and use by dates of medicines in the labour ward treatment room. We checked 7 different medicines and found them all to be within date and the stock levels were correctly documented. During assessment, we found the baby milk fridge on the postnatal ward was unlocked with no control or monitoring over who had access. There were open bottles of milk formula which were labelled with baby’s names and used by dates; however, we were not assured this practice was safe and did not safeguard against any tampering of milk products. The milk fridge temperature audits showed that the fridges had been continually out of range for months, putting babies at risk of harm. There was no visible guidance for domestic staff outlining what actions to take if temperatures were out of range. Ward managers had no oversight on fridge safety. We raised our concerns with the trust who acted and decommissioned those fridges that were faulty and disposed of all the milk products within them. They provided assurances staff would be given clear instructions on what action to take in future. On a labour ward treatment trolley, we found an ampoule of wound irrigation fluid stored with intravenous ampoules (IV) injections fluids in a neonatal resuscitation trolley. There was a risk the wrong medication may be mistakenly administered by staff. We identified this as an immediate risk, and it was removed by the assessment team and handed to midwifery staff who escalated to senior leaders.

Staff did not always follow the services safe and secure storage of medicine in clinical area policy, which put women, birthing people, and babies at risk of harm. As a result of our concerns the trust took action to carry out a complete audit of all medicines and milk products in the department. Fridges were decommissioned, and staff were updated on correct monitoring processes. We saw evidence during the assessment where blood products had not been given in line with national guidance. There had been a lack of clinical monitoring of the women and birthing person putting them at risk of harm. National NICE guidance states for patient safety the persons conditions and vital signs should be monitored before, during and after blood transfusions. On reviewing medicine records staff did not always complete mandatory fields within the documents, some had names, dates and times missing. There was no effective audit process in place to ensure medicine records were completed as required