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Hull Royal Infirmary Maternity Services: Urgent and significant changes needed to improve patient care after CQC says hospital 'not fit for purpose'

The Women’s and Children’s Hospital at Hull Royal Infirmary, part of Hull University Teaching Hospitals NHS Trust, provides maternity care to all of the Hull and East Yorkshire region. Hull and East Yorkshire is a large region relying solely on the care of HRI to provide safe maternity care for mothers and babies.

The Care Quality Commission (CQC), the independent regulator of health and social care in England assess services to ensure care is safe, effective, compassionate and high quality.

The CQC assessed Hull Royal Infirmary (HRI) to be inadequate and described the maternity services as a chaotic environment which was not fit for purpose”.

Rebecca Tramaseur and Victoria Harris, specialist medical negligence solicitors, discuss the findings of the CQC report and the urgent changes that are needed to improve patient care.

Training of Staff 

The CQC identified HRI had no policy in place to outline what training was mandatory. The CQC found that only 39% of staff had completed the perinatal institute growth assessment protocol training and 51% of all staff had completed fundal height measurements training. 

This training is crucial to ensure that staff correctly identify babies that are small for gestational age. The CQC identified HRI had failed to identify several babies who were small for gestational age.

If a baby isn't identified as small for gestational age and care managed appropriately, there's a risk of stillbirth or developmental difficulties for the baby.

Environment and Equipment

The CQC identified HRI wasn't always safe. It said waiting areas didn't facilitate effective monitoring resulting in risks deterioration in babies conditions would not be noticed or acted on because a number of departments shared a waiting room. 

The CQC found there was no neonatal resuscitaire on the antenatal day unit and no plans on how to access one in an emergency. A neonatal resuscitaire is used to provide support to babies breathing and in some cases resuscitaire babies if needed.

Assessing and Responding to Risks

The report also raised concerns about the maternity department’s systems and processes for managing and responding to patient risks. The CQC identified that risk assessments weren't always completed prior to admission or when transferring patients between wards. There were also concerns that staff didn't always keep detailed records of people’s care and treatment.

The report also noted that patients didn't receive treatment within the agreed timeframes despite these issues being identified in previous serious incidents and investigations.

The CQC report states that risks associated with the inadequate-triage systems had been highlighted both internally following serious incident review and by external bodies as part of an investigation by the Healthcare Safety Investigation Branch (HSIB) cases, However, the CQC saw no evidence of action taken to prevent reoccurrence or mitigate risk. The report states that the service must ensure there is robust risk assessments in place for women and birthing people presenting to the service.

Safety Incidents Not Managed Well 

In addition to the issues surrounding assessing and responding to the risks to patients, the CQC also found that the service didn't manage safety incidents well. 

The report provides an example that over a 12-month period, there were 56 occasions where babies were born small for gestational age posing a risk to the baby and further action was needed to mitigate the known risk. 

Where serious incidents did occur, the CQC found that these weren't always investigated in a timely manner with long delays. One incident wasn't reviewed for 12 months. The report also found that there was no evidence that changes had been implemented and effectively embedded following feedback from staff.

The CQC report states that the service must assess, monitor and mitigate the risk relating to the health, safety and welfare of women and birthing people.

The Human Impact of Maternity Failings 

We've supported families in Hull, East Yorkshire and across the North of England who've been affected by failings in maternity care. 

We've both worked with families whose babies weren't identified as small for gestational age or where babies had concerning heart-rate that wasn't monitored or acted upon. We see the devastation losing a child or having a child with lifelong disabilities has on the families.

We support families through medical negligence claims to access the specialist treatment their children with lifelong disabilities need such as ongoing physiotherapy. We also support parents to access psychological treatment for the injuries they suffer through traumatic maternity experiences.


Pregnancy and childbirth is a big moment in someone’s life. Parents deserve safe patient care to bring their children into the world. When maternity services are inadequate and unsafe, as this CQC report has identified, families’ lives can be turned upside by the failings in care owed to them. Each parent and child isn't a statistic of a report, but a life changed forever by unsafe care.

As medical negligence solicitors each family we support wants to ensure the same thing doesn't happen to other families. It's extremely concerning to learn through this CQC report that incidents and investigations weren't being acted on and lessons weren't being learned.

Lessons must be learned to improve care. We're hopeful that following the CQC's report in relation to HRI, the Hospital Trust make significant changes to improve the care provided to families across Hull and East Yorkshire.

Find out more about Irwin Mitchell's expertise in supporting parents affected by maternity care issues at our dedicated birth injuries section.  

Hull Royal Infirmary's maternity unit has been rated as inadequate, with Care Quality Commission (CQC) inspectors describing it as a "chaotic environment which was not fit for purpose".

The CQC said the "design, use of facilities, premises and equipment did not always ensure women and birthing people were safe".”