Mothers endured emergency caesarean section delays and suffered unnecessary blood loss at a maternity ward, a health watchdog has found.

The Care Quality Commission (CQC) has published damning reports on all three maternity services run by the Maidstone and Tunbridge Wells NHS Trust (MTW) after an inspection last year.

Maternity services at Tunbridge Wells Hospital at Pembury have been rated "inadequate" overall.

It was given the same rating for safety and "requires improvement" for how it is led.

Published today (February 16), the CQC report noted "there were concerns around the service’s infection control measures and inspectors found no cleaning schedules in place for areas such as the birthing pool".

Inspectors also found staff had not been using a standard tool to check women's needs when they arrived at the department.

This meant patients were being assessed differently based on which member of staff was caring for them.

The report adds daily safety checks of emergency and specialist equipment, and their records, were not always completed.

Meanwhile, medicines weren’t always prescribed and administered safely, plus not stored securely.

Some records where people had been given controlled medicines, such as strong pain relief, were missing necessary signatures.

This was alongside staff not always having dedicated time to study, with leaders not effectively supporting them in accessing specialist training for their role.

The team carried out the inspection on August 23 and comprised a CQC lead inspector, a CQC senior specialist, two midwifery and one obstetric specialist advisors.

It was overseen by the CQC’s deputy director of secondary and specialist care, Carolyn Jenkinson.

She explained: “When we inspected maternity services at Maidstone and Tunbridge Wells NHS Trust, we found a service with staff who were doing their best to provide safe care to women and people using the service despite ineffective systems and poor leadership.

“Across the maternity services, leaders didn’t have good systems in place to report and investigate incidents.

"We saw occasions at The Tunbridge Wells Hospital at Pembury where there had been delays in emergency caesarean sections, people had delays to birth being induced or people had experienced major blood loss after birth.

"These incidents were opportunities for the service to identify where improvements could be made and learn lessons for the future."

Information showed the rates of postpartum haemorrhage (PPH) were higher than the national average among some of its patients.

This was after inspectors found the service had been estimating, rather than measuring, blood loss.

They later discovered the service had been using out-of-date guidance for staff on managing PPH.

The CQC also requested that changes are made to how emergency caesarean births are handled.

It added: "Information from incidents and service reports showed that over the past 12 months there were ongoing recurrent delays in emergency caesarean section (LSCS) births.

"[This was] due to a lack of a second theatre overnight, lack of theatre availability due to use, lack of theatre staff [and an] over-running elective caesarean sections list.

"This meant an increased risk of harm, including cases reported by the service such as babies with acute fetal hypoxia, had emerged due to delayed births."

It continued: "Following our inspection, we served a warning notice asking the trust to make significant improvements on timely action of emergency caesarean births, risk management, and governance and oversight of the service.

"The service was required to submit an action plan, and we will continue to monitor progress in relation to this."

The CQC insists "a warning notice" has now made to ensure the Trust focuses on areas of concern.

The body says it will return to check if the required improvements have been made for the future, and will "monitor the Trust closely to make sure women, people using the services and their babies are safe.

"If further improvements are not implemented and embedded, we will not hesitate to take further action to ensure we are confident people are receiving the safe, consistent care they deserve," it said.

The other two maternity wards in the Trust, Maidstone Birthing Centre and Crowborough Birthing Centre, were both given a rating of "requires improvement".

The inspection was the first time maternity services at The Tunbridge Wells Hospital at Pembury has been rated on its own.

Prior to a CQC consultation in 2018, maternity and gynaecology services were inspected and rated together.

They had previously received a "good" rating in 2015.

A statement released by the Trust said it had taken steps to address all of the recommendations made by the CQC, the majority of which had been completed.

“I understand this report may raise questions for people using our maternity services...”

This included:

- undertaking a multidisciplinary workforce review

- the implementation of new guidelines on induction of labour

- additional training and new guidelines on the management of PPH

- streamlining of the emergency theatre pathway

- improving use of the data

Trust chief executive, Miles Scott, said: “MTW has a reputation for continually developing and improving care.

"I want to reassure people using our maternity services that we are addressing all of the issues raised by the CQC and have already implemented the majority of their recommendations.

“This work has the highest priority in our organisation and I am proud of the hard-working maternity teams who are dedicated to providing the best possible care at what is such an important time in people's lives.”

Jo Haworth, Trust chief nurse, said: “I understand this report may raise questions for people using our maternity services.

"Please contact the Trust or your midwife so we can answer any questions you may have.

“I am working with our maternity teams to use this report, along with feedback from the recent maternity survey and the local Maternity and Neonatal Voices Partnership, to support the ongoing improvements of the service.”