Andrew PickenBBC Scotland
Staffing shortages and a “culture of mistrust” led to delays and patients being harmed at one of the busiest maternity units in the UK, a review has found.
An inspection of maternity care at the Royal Infirmary of Edinburgh said some women waiting for labour to be induced had experienced delays of more than 24 hours.
It also said staff were reluctant to submit safety reports and had raised concerns about being overwhelmed and unsupported.
The damning findings echo those of NHS Lothian's own review into the troubled maternity unit last year – but the health board insisted it was making progress in improving and investing in its women's services.
The review of Edinburgh's maternity unit follows a BBC Disclosure investigation which heard calls for urgent action to improve maternity safety across Scotland.
The investigation heard from a number of families who had experienced poor and sometimes deadly care.
Concerns about Edinburgh's maternity unit were raised in 2024 by whistleblowers, which forced NHS Lothian to hold an internal safety review.
It concluded that mothers and newborn babies had come to harm because of staffing shortages and a “toxic” workplace culture.
An unannounced inspection was carried out in June this year by safety watchdog Healthcare Improvement Scotland (HIS).
It has now * published its report, which found that staff were “working hard to provide compassionate and responsive care in very * challenging circumstances”.
It made 26 requirements for improvement and escalated “serious concerns” about the unit to NHS Lothian and the Scottish government.
The inspectors found:
- Delays of between seven and 15 hours for an obstetric review within the triage department for some women, and that the induction of labour process had been delayed by up to 29 hours
- Only 13% of the charts for patients' essential observations, such as blood pressure and heart rate, were fully complete at the time of the visit. One inspector had to tell staff that these observations indicated a potential deterioration in a woman's condition
- Delays in the escalation of care resulted in “significant adverse outcomes” for women
- Errors were occurring because of poor communication between different care areas, resulting in problems such as missed medication
- The majority of staff described a negative culture with a lack of visible senior management. Many staff were “emotional and tearful” talking about the “overwhelming feeling of helplessness, frustration and worry for not only patient, but staff safety”
- Five of the six single rooms within maternity triage had no call bell system available. One woman told inspectors she had been in pain but had no way to get staff attention
HIS chief inspector Donna Maclean said all interactions observed during the inspection between women, babies and families were “positive and respectful”.
“Some staff were complimentary and described their line manager as supportive,” she said.
“However, the majority of the multi-disciplinary team we spoke with were frustrated at staffing levels and told us this presented a safety risk, which they'd raised on multiple occasions with managers.
“They shared their concerns of being overwhelmed, unsupported and not listened to.”
There were concerns about the mix of skills within the department, challenges in providing one-to-one care for women, and delays to observations or the escalation of clinical concerns.
“Our inspection has highlighted gaps in incident reporting and a reluctance to submit incident reports, with staff describing a culture of mistrust,” she added.
“These are concerning issues that may have significant impact on the learning from adverse events in the system and reduce opportunities to improve safety.
“Women told us of mixed experiences within the hospital. Whilst some were complimentary of their care, they also informed inspectors of poor communication that left them feeling uninformed and with no ‘voice' in their care.”
BBC Scotland News has spoken to more than a dozen midwives, on an anonymous basis, who work at Edinburgh's maternity unit.
They explained some of the challenges they faced in the unit when it came to dealing with pressures such as short staffing and workload.
NHS Lothian's 2024 review upheld or partially upheld 17 concerns about safety and concluded “there is no dispute that there have been safety concerns, near misses and actual adverse outcomes for women and babies”.
At the time, BBC Scotland spoke to some families with experiences of poor care at the maternity unit.
This included Naomi Robertson, whose son Roddy was born there in August 2023.
A review of his birth found he suffered a brain injury after multiple missed opportunities for observation and treatment due to short-staffing and high numbers of complex patients at the hospital.
The HIS inspection in June this year also found evidence that suggested not all serious birth tears were being recorded properly, and that the number of women experiencing a significant blood loss could be being under-reported.
Staff also described an environment where staffing numbers varied vastly on a shift-to-shift basis, with HIS observing a reduced availability of midwives by up to 50% on some shifts and noting “at times there was no staff to undertake care needs”.
The leading cause for maternal death in the UK is venous thromboembolism, where a blood clot blocks the flow of blood.
In the incident reports provided by NHS Lothian, HIS found that errors regarding venous thromboembolism risk assessments and medication was the second leading cause for a patient safety incident report to be submitted by staff in the six months prior to the inspection.
Elsewhere, inspectors found gaps in incident reporting, including some stillbirth reports not being submitted until 11 days after the death, with some workers describing a “reluctance to submit incident reports due to perceived repercussions and a culture of mistrust”.
And some student midwives at the maternity unit said they felt pressure to ‘just get on with it' without adequate support, with some of them then being involved in patient medication errors.
In May, NHS Lothian issued an apology to maternity care staff after an investigation found a toxic workplace culture across its women's services.
Prof Caroline Hiscox, chief executive of NHS Lothian, said the HIS report “effectively endorses” its ongoing programme to improve patient safety and working culture.
This includes hiring 70 extra midwives, who will all be in post by the end of December.
She added: “I know these reports are concerning and I apologise to women and their families and can reassure them that these issues are being taken extremely seriously.
“An improvement plan is ongoing in NHS Lothian after whistleblowing concerns were raised in 2024 and we have been very * clear that wider ranging matters, such as staffing, recruitment and working culture within the department, will take time to resolve.
“Significant investment and improvements have already been made.”
She added: “I want to reiterate the apology we made to staff earlier in the year when they told us about their concerns over staffing numbers and about a working culture that was difficult, and where bad behaviours were tolerated. That is not acceptable in any workplace.
“We know there is still more to do to ensure our staff feel * supported at work, safe to raise concerns and able to thrive.”
