CQC report demonstrates serious concerns about maternity care in Sussex

Posted: 30/06/2025

Maternity care in Sussex is under serious scrutiny. On Monday, Health Secretary, Wes Streeting, announced a national probe into NHS maternity and neonatal services, with University Hospitals Sussex NHS Foundation Trust being identified as one of the ten most concerning trusts to be investigated as a priority. This follows a surprise two-day inspection by the Care Quality Commission (CQC) at Royal Sussex County Hospital in February 2025, focusing on the A&E and maternity departments. Results are pending.

According to the CQC website, maternity services at Royal Sussex County Hospital are currently rated inadequate with maternity services at the Princess Royal Hospital, St Richard's Hospital and Worthing Hospital rated as requires improvement.

A report published by the CQC in December 2021 noted that an inspection of maternity services had taken place due to concerns raised about safety and quality of service. There had been instances of staff whistleblowing, patient complaints and information from other regulatory bodies. The report focused its findings on the Royal Sussex County Hospital and the rating in the category of 'safe and well-led' went down to ‘inadequate'.

The report found that women in the maternity assessment unit were reviewed by a midwife within one hour of arrival but waited up to six hours to be reviewed by a doctor. The National Institute for Health and Care Excellence guidelines for safe midwifery staffing (2015) defined a delay of 30 minutes or more between presentation and triage as a ‘red flag event’. This long wait for clinical assessment was a significant risk for women attending the department.

The service did not have enough maternity staff with the right skills and training to keep women safe from avoidable harm and the report noted that all staff they spoke to put low staffing numbers as their biggest concern. Comments provided included 'I feel it is only a matter of time before something bad happens', 'Staff are reduced to tears every day because it is so short staffed' and 'I have a constant sense of dread that something awful will happen'.

No doubt linked to the pressure of low staffing numbers, the report identified that training session attendance was an area of concern. The average nursing and midwifery staff attendance for annual mandatory training sessions was 8.73% below trust targets. Records also indicated that only 46% of midwives attended skills drills training in the year prior to the inspection - 44% below the training target.

Of particular concern to us as clinical negligence lawyers who always hope that lessons will be learnt and changes made when a patient safety incident is identified, is the fact that the report found that the service did not manage safety incidents well. Staff did not have time to report incidents and near misses. Many only reported what they construed as the most serious incidents, and this was typically done only after their shifts had finished. They indicated that they had been instructed to stop reporting low staffing as an incident as it was a known risk. Some did not understand the duty of candour, a legal obligation to be open and transparent with patients when something has gone wrong.

Leadership was also found to be disjointed and ineffective. Managers were identified as failing to share learning with staff about never events that had occurred elsewhere in the trust ('never events' refer to serious and preventable incidents that should not occur given the guidance and safety recommendations). This reduced staff opportunities to change and improve their practice and offerings. Many also described feeling undervalued, disrespected, and unsupported in their roles, which correlated to a lack of morale. A culture of bullying and harassment was also noted. A significant number complained of exhaustion and dehydration, and reported they were unable to provide the level of care they desired.

After the September 2021 inspection in which the ratings for all four maternity services at the trust went down, the CQC took enforcement action by serving a warning notice that asked the trust to make significant improvements. It inspected the maternity services again in April 2022 and found the trust had complied with the terms of the warning notice but asked the trust to make additional improvements by issuing requirement notices. The outcome of the recent inspection in February 2025 is awaited.

In maternity care, even brief delays or misjudgements can result in babies suffering serious harm or, tragically, dying. At Sussex specifically, staff shortages leading to delays in care have been directly attributed to causing baby loss. The Department of Health and Social Care has confirmed that NHS chief executive, Jim Mackey, will meet with Sussex trust leaders to ensure improvements are made.

Penningtons Manches Cooper is committed to supporting families affected by substandard maternity care in Sussex and beyond. If you or a loved one has been impacted and are considering legal action, we are here to provide compassionate and expert guidance through these complex and distressing matters.

The official CQC summary of the inspection findings and links to relevant reports can be found here.

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