Scottish hospital ordered to improve maternity safety decade after baby deaths investigation
Potential delays to care and treatment were highlighted as one of the concerns when Healthcare Improvement Scotland inspected the hospital.
A Scottish hospital has been ordered to improve patient safety a decade after it was at the centre of a baby deaths investigation.
Healthcare Improvement Scotland carried out an unannounced inspection of the Ayrshire Maternity Unit at Crosshouse Hospital in Kilmarnock in October last year, and said the ward had fallen short of 16 different standards.
This comes almost 10 years after an investigation into baby deaths at the hospital which led to a Scottish Government review. Between 2008 and March 2016, there were four significant adverse event reviews on stillbirths at the unit.
The HIS report, published on Wednesday morning, has found 16 requirements, two recommendations and 10 areas of good practice.
Requirements include better fire safety, incident reporting, ensuring women can receive timely access to midwifery telephone assessments, better governance and oversight of the maternity ward, and ensuring patients get the right care at the right time.
The report also said there needed to be ongoing engagement amongst staff to ensure transparency and to make sure significant adverse event reviews are done on time.
Inspectors also said the hospital must take steps to ensure patient equipment is clean and ready for use.
Read more: National investigation into Scotland's maternity services to be launched over 'serious concerns'
Donna Maclean, chief inspector at HIS, said: “We raised concerns regarding potential delays to care for women accessing maternity triage and potential gaps in incident reporting, which may impact on the learning from adverse events and reducing opportunities to improve safety.
“We also raised concerns regarding fire safety.
“Other areas for improvement identified include flushing of infrequently using water outlets and some improvements required in the cleanliness of patient equipment.”
The report did however find the ward excelled at supporting families, giving families the opportunity to stay in the hospital during births, and having a dedicated area for bereaved families.
Ms Maclean said: “During this inspection we observed cohesive team working in all areas inspected.
“Maternity staff we spoke with described positive working relations between midwifery, obstetric, anaesthetic and the healthcare support team. Staff described feeling supported to escalate staffing issues and concerns to their senior charge midwife.
“Women within the unit told us they felt listened to and supported in making decisions about their care - women described positive experiences of communication and compassionate interactions with staff.
“Women and their families also told us they would be happy to recommend NHS Ayrshire and Arran maternity services to their family and friends.”
Health Secretary Neil Gray said the inspection report demonstrates the hospital inspection system is working, and feels confident the maternity unit is now safe.
Speaking to BBC Radio Scotland Breakfast, Mr Gray said: “I welcome Healthcare Improvement Scotland’s report - it demonstrates that our inspection regime is working to ensure that localised issues are being addressed, and I expect [NHS] Ayrshire and Arran to respond timeously, to ensure that all of the recommendations, all 16 recommendations, are delivered as fast as possible.
“This is the fifth inspection that Healthcare Improvement Scotland has carried out at our acute maternity services across Scotland, when we consider that NHS Tayside has now implemented all of the recommendations in its report into the maternity services at Ninewells.
“I expect a similarly timeous response from Ayrshire and Arran in Crosshouse to ensure that the safety of patients is absolutely paramount, and that we can ensure that our maternity services are safe for women and their families.”
When asked if these maternity units are safe today, the health secretary said: “Yes, I believe they are.”
Jennifer Wilson, nurse director of the Ayrshire Maternity Unit, said the health board is committed to making the necessary improvements on the back of this inspection.
She said: “NHS Ayrshire and Arran is committed to the provision of high standards to ensure our patients receive safe and dignified care at all times.
“Our teams have a strong focus on ensuring that improvements are made to deliver the best possible care across health and social care services.
“As a learning organisation, NHS Ayrshire and Arran values scrutiny and inspection of our services. We acknowledge the recent HIS report following their visit to Ayrshire Maternity Unit.
“The report highlighted cohesive multidisciplinary team working and positive working relationships and demonstrated that our teams provide a good standard of care for families, supporting patients to make decisions about their care.”
She added: “We acknowledge that there are areas where we need to make further improvements, and these have been addressed within our action plan.
“I would like to take this opportunity to thank our teams for their hard work in caring for the women, babies and families who use our services.”
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