Royal London Hospital warned over security at its maternity unit

The biggest hospital in Europe has been ordered to improve security on its maternity ward after inspectors found that mothers “might leave the unit with the wrong baby”.

Some babies born at The Royal London Hospital had no name tags – which could lead to them going home with the wrong families or even being given medication meant for another baby, the Care Quality Commission (CQC) said.

Inspectors said there was “lax” practice of checking babies’ name bands, saying that this could create a “risk that a baby might receive medication intended for another baby, and mother might leave the unit with the wrong baby.”

Meanwhile another hospital run by the same organisation, Whipps Cross University Hospital, was lambasted by inspectors who said they did not find a single element of outstanding care across the whole hospital.

Inspectors oberved one dying patient at the East London hospital asking for vegetarian food only to be told by a nurse: “You will not get vegetarian diet in here.Where you think you are, in a hotel?”

Other patients nearing the end of their lives were left to suffer in pain.

At The Royal London, inspectors also found there were not enough midwives on the delivery suite to provide safe cover for all women.

And midwives said they had been ordered by managers not to raise concerns about low staff numbers.

There was a “mixed” view about how caring staff were at the hospital – one mother told inspectors she was treated as “childish” because she was upset that her baby had been taken into special care.

Inspectors, who visited The Royal London (pictured) in July this year, said they also observed some “intra-cultural issues and some bullying behaviour” both between groups of midwives and between midwives and patients.

Doctors and midwives on the postnatal ward referred to patients by their bed numbers rather than by name, the CQC said.

Last year 4,645 babies were born at The Royal London – the largest standalone acute hospital building in Europe.

The CQC has ordered the Barts Health NHS Trust, which runs the East London hospitals, to “urgently” improve security in maternity after rating the service “inadequate”

The regulator has also said Whipps Cross must improve on a number of key areas – including patient pain management.

On The Royal London, Professor Sir Mike Richards, chief inspector of hospitals at the CQC, said: “We were most concerned about the standard of care around maternity and gynaecology services.

“Staffing on maternity wards was sometimes inadequately covered – but most worrying of all was the lack of a safe and secure environment for new born babies.

“At the time of our inspection, we raised this with the Royal London Hospital as a matter for their urgent attention.”

A spokeswoman for the Trust said: “We acted immediately to improve the security of babies at The Royal London Hospital.

“It’s important to stress that these reports are based on observations from five months ago – since then we have subjected our processes and procedures to forensic scrutiny.

“As a result we’ve introduced new baby ID tags, we’ve reviewed our procedure for locking down the hospital and refreshed our policy.

“We have recirculated our policy to all staff and now test it every single month.

“Women should be assured our services are safe and we will review our processes regularly to ensure they remain safe.”

The inspection report for Whipps Cross highlighted a number of areas of concern – particularly surrounding dying patients.

Inspectors said: “On a few instances, during our unannounced visit, we observed patients were visibly in pain, but staff did not respond to this by providing them with analgesia.”

The CQC said there were “many examples of a lack of compassion towards patients nearing the end of their lives”.

“One patient looked dirty with stains all down the front of their nightwear and staff had neither noticed it nor took any actions to wash and care for the patient,” the report states.

The regulator also raised concerns about infection control practice in the surgery service – having observed some staff wearing their surgical scrubs in other parts of the hospital, including the canteen.

The spokeswoman for Barts Health added: “The CQC found that since its last inspection end of life care at Whipps Cross is now safer, more effective and better led.

“At daily safety huddles team will discuss patients who are at the end of their life to ensure we appropriately identify and provide them with safe and compassionate care.

“We have also made a quiet space for sensitive conversations to be held in privacy, and overhauled our training in end of life care with the oversight of Board-level leadership to ensure progress.”

On Whipps Cross, Sir Mike said: “Overall, we have rated the service provided by Whipps Cross as Inadequate.

“In the past year there have been some big changes in the management at Whipps Cross and the hospital is moving in the right direction.”

Alwen Williams, chief executive of Barts Health NHS Trust, said: “These reports make clear that the quality of care for patients at our hospitals is getting better all the time.

“I’m very grateful for the dedication and passion our staff show every day and night.

“We still have much to do and we must tackle all the areas where we are still letting our patients down, as well as taking inspiration from where we are doing well.

“I am confident that Barts Health is now on the right track and with the support of our partners and our committed workforce we will continue to improve.”

Inspectors’ key findings at Whipps Cross and Royal London Hospitals

Here are some of the additional findings from the CQC reports.

Key findings from the inspection report of Whipps Cross include:

:: Not all patients were provided with one-to-one care during labour as recommended by health officials.

:: Inspectors said they found “pockets of poor culture” with evidence of bullying and inequality.

:: They said they saw examples of lack of compassionate care.

:: A number of patients raised concerns about agency staff. One patient said: “I have noticed that agency nurses are less caring and less bothered, sometimes ignoring patients”. A patient with a learning disability told inspectors that an agency nurse had been angry when they had been incontinent.

:: Nurses also raised concerns about the quality of agency nurses – which were used frequently. On some wards the use of agency staff was 50-70%.

:: Inspectors said that there was “extensive use” of open backed hospital gowns – which led to many patients inadvertently exposing themselves.

:: They observed a doctor informing a relative their loved one was deteriorating in the middle of a ward – affording them no privacy in a difficult moment.

:: In one month alone, almost 300 patients were moved between medical wards in the middle of the night.

:: A number of staff raised concerns about ongoing issues of bullying and harassment. Inspectors said: “A number of nursing staff in different surgical areas told us about ongoing issues of bullying and harassment. They were visibly distressed and told us they did not feel supported by their managers and service leaders. They felt the trust was not supportive of whistle-blowers. They gave us examples when they were blamed for and unprofessionally treated after raising an issue or a complaint.”

Key findings from the inspection of The Royal London include:

:: Frequent problems with insufficient availability of sterile equipment in theatres.

:: A two week backlog of outpatient appointments waiting to be booked – some patients waited for over a year for follow up appointments.

:: The nutrition and hydration needs of patients were met, though in some busy departments this was enabled by relatives of patients.

:: Nine never events were reported at the hospital between August 2015 and July 2016 – these are wholly preventable errors that occur in medical care. These blunders included: A surgeon leaving an object inside a patient after finishing an operation, a wrong tooth extraction, “wrong-site implants” and incorrect medication being given to a patient,

:: During the inspection some patients in A&E had to wait 1 hour and 20 minutes for an initial assessment from a medic – even though national guidance suggests the majority of people should be assessed by a clinician within 15 minutes.

:: Some medics had to complete mandatory training in their own time or as part of holiday leave.

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