Recurring concern

Unsafe staffing and cover arrangements for midwifery care

First to latest report 25 Feb 2014 — 29 Sep 2022

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
9

What this concern includes

Includes deficiencies in midwifery staffing capacity or arrangements, including unsafe shift length, inadequate breaks, insufficient leave or sickness cover, unreliable on-call support, and recruitment or retention failures where these directly threaten safe midwifery care.

What is not included
  • Excludes generic staffing, workforce or fatigue concerns outside midwifery care.
  • Excludes failures of midwifery competence, clinical referral, documentation or supervision where staffing or cover arrangements are not the shared unsafe condition.
  • Excludes general maternity-service deficiencies that do not concern midwifery staffing, shifts or cover.
  • Excludes isolated poor clinical decisions where no midwifery staffing or cover deficiency is identified.

Reports and published responses 5 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Sunderland

    AI-generated summary

    Charlotte Emma Warkcup · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Charlotte Emma Warkcup died at Sunderland Royal Hospital on 23 December 2021, two days after she was born. The report described concerns about delayed recognition of the severity of her condition, delays transferring her mother to hospital, and delayed access to the delivery suite. It also identified concerns about the safety of standalone midwife-led birthing centres, midwife recruitment and retention, and detection of babies who are small for gestational age.

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    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient recruitment and retention of midwives for continuity of care

    Wider context from the report

    “2. The recruitment and retention of midwives to ensure continuity of care ”

    Source location

    Charlotte Emma Warkcup · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Invest £165 million to grow and support the maternity workforce and improve neonatal care.

    Verbatim wording from the response

    “The Department recognises that professional staff is the NHS’s most valuable asset, and the importance of ensuring that maternity units have the appropriate number and mix of staff to deliver high quality care for all women.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 October 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Expand midwifery training places by 3,650 over four years.

    Verbatim wording from the response

    “The Government has also committed to expanding midwifery training places by 3,650 over a four-year period with an increase of 650 in September 2019 and 1,000 in each of the subsequent years.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 October 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide non-repayable annual training grants and additional financial support for eligible students and recruitment-shortage specialisms.

    Verbatim wording from the response

    “And as part of the biggest nursing, midwifery and Allied Health Professional recruitment drive in decades, since September 2020, the Government has made available:”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 October 2022

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement the NHS People Plan’s staff-retention measures, including wellbeing guardians, healthier working environments, flexible working and psychological support.

    Verbatim wording from the response

    “To improve working conditions to deter people from leaving the profession, the NHS People Plan has been developed to focus on improving the retention of NHS staff by prioritising staff health and wellbeing. This includes a wellbeing guardian role, a focus on healthy working environments, and empowering line managers to hold meaningful conversations with staff to discuss their wellbeing, and a comprehensive emotional and psychological health and wellbeing support package.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 7 October 2022

    Open published response

  2. Nottinghamshire

    AI-generated summary

    WYNTER SOPHIA ANDREWS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Wynter Sophia Andrews died after being delivered by caesarean section on 15 September 2019, following missed opportunities to monitor her wellbeing and concerns that she should have been delivered earlier. The report identified concerns about the lack of robust initial critical analysis of deaths and an unsafe culture within Midwifery Services, including failures to respond to staff safety concerns, facilitate professional challenge, and make decisions based on individualised patient risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide sufficient midwifery care capacity for multiple families

    Wider context from the report

    “(a) Failure to listen to and respond to staff safety concerns I have made findings that the Maternity Services were operated in an unsafe manner on 14 – 15 September 2019. Staff told me this was not the first time, nor the last time, that they have been asked to care for multiple families simultaneously, meaning that those families cannot receive the time, focus and dedication they require. Staff further told me that they have repeatedly raised their concerns about patient safety, but their concerns have been met with silence. I saw evidence that staff were repeatedly raising their concerns through the Datix system, but they told me they would receive no feedback in reply nor would anything change. ”

    Source location

    WYNTER SOPHIA ANDREWS · Prevention of Future Deaths report
    Page 3 · concerns

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Recruit additional midwives and continue recruitment, using agency staff and overtime temporarily to address the identified staffing shortfall.

    Verbatim wording from the response

    “• In December 2019, a Birthrate Plus (BR+) staffing review on maternity services was undertaken. The NUH report by the national body undertaking this work was published in June 2020. This highlighted that, when considering the acuity of care required in the maternity services, there was a shortfall in the midwifery staffing establishment of 73 Whole Time Equivalent (WTE). We have been recruiting to resolve this issue and fifteen newly qualified midwives commenced in September, 23.84 WTE new starters were recruited in late October (26 individuals) and will start in January 2021. A further recruitment campaign is underway. Agency staff and overtime have been offered to bridge the gap in the interim. Staffing levels and acuity are being monitored daily, and activity diverted or reduced, or staff redeployed, as necessary to maintain safe staffing levels.”

    Source location

    2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
    Page 4 · response
    Published 1 December 2020

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Pilot an obstetric handover checklist incorporating staff-break information to support safe-staffing assessment.

    Verbatim wording from the response

    “• A medical obstetric handover checklist is being piloted and will include a question for the outgoing medical team regarding whether they have been able to take breaks. This will be used, along with the midwifery acuity, to assess the safe staffing of the unit for the preceding 12 hour period.”

    Source location

    2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
    Page 4 · response
    Published 1 December 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate twice-daily senior leadership Safe Today visits and safety briefings assessing staffing, acuity, care and escalation needs across both maternity sites.

    Verbatim wording from the response

    “Safe Today Process:”

    Source location

    2020-0202-Response-from-Nottingham-University-Hospitals-NHS-Trust_Redacted.pdf
    Page 4 · response
    Published 1 December 2020

    Open published response

  3. Manchester South

    AI-generated summary

    Caspian Thorn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Shortage of midwives in the enhanced midwifery team

    Wider context from the report

    “1. A feature of the evidence was a lack of communication between the teams of midwives and social worker. This meant that it was not picked up that his mother had missed a key fetal growth scan and that a small baby was not monitored for the period between 10th September until his birth on 24th September. The inquest heard that contributing to this was a shortage of midwives in the enhanced midwifery team and a shortage of experienced social workers in the Local Authority at the time; ”

    Source location

    Caspian Thorn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Leicester City and South Leicestershire

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    Dayani Chauhan-Ahmed · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dayani Chauhan-Ahmed was born in poor condition after a prolonged second stage of labour exceeding 5.5 hours and died after intensive care was withdrawn with parental consent. The substantive concerns included ineffective communication about the length of labour, uncertainty about staff knowledge and adherence to escalation procedures, and insufficient midwifery and medical availability during periods of extreme demand.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a confirmed Trust policy for the midwifery SOS attendance system

    Wider context from the report

    “(3) The Trust should consider arranging for additional midwifery and medical availability to assist during times of extreme demand on the service. The current informal “SOS” system for midwifery attendance, while promising, should be further explored and confirmed in Trust policy if considered to be effective. ”

    Source location

    Dayani Chauhan-Ahmed · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the Escalation Policy to include guidance on the informal SOS system.

    Verbatim wording from the response

    “4. The Head of Midwifery is to ensure that by the end of September 2014 the Escalation Policy (the Transfer of Activity and Closure Policy) will be reviewed and will include guidance on the informal ‘SOS’ system. Once this has been completed the policy will be disseminated in accordance with normal Trust practice. Additionally, the Head of Midwifery and Deputy Clinical Director between them will ensure that a”

    Source location

    Response from University Hospital of Leicester NHS Trust
    Page 2 · response
    Published 30 June 2014

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    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Disseminate the revised Escalation Policy electronically to all midwifery and medical staff in the Clinical Management Group.

    Verbatim wording from the response

    “4. The Head of Midwifery is to ensure that by the end of September 2014 the Escalation Policy (the Transfer of Activity and Closure Policy) will be reviewed and will include guidance on the informal ‘SOS’ system. Once this has been completed the policy will be disseminated in accordance with normal Trust practice. Additionally, the Head of Midwifery and Deputy Clinical Director between them will ensure that a”

    Source location

    Response from University Hospital of Leicester NHS Trust
    Page 2 · response
    Published 30 June 2014

    Open published response

  5. Inner South London

    AI-generated summary

    Arthur Brockett-Deakins · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Arthur Brockett-Deakins was born in poor condition on 16 December 2007 after complications during labour and suffered severe disabilities resulting from acute profound perinatal hypoxic-ischaemic encephalopathy. He died at home on 18 October 2011 from respiratory problems. The report identified concerns about failure to escalate an abnormal CTG, administration and monitoring of Syntocinon, CTG interpretation and display of the maternal heart rate, and the organisation and support of a private midwifery-led service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unsafe staffing and shift arrangements for private midwifery services

    Wider context from the report

    “4. Models of private midwifery led services for low risk pregnancy: The private midwifery caseload for low risk pregnancies was managed by a pair of midwives who set up the service to provide continuity of care. The midwife service that was operating when ████████ was pregnant was not adequately documented. No job description was seen by the court and the referral and operational arrangements were discussed, but no documentation was brought to the court. There was no evidence of risk assessment. Although NHS employees were required to be self sufficient in terms of annual leave and sickness cover, on call arrangements and use of NHS personnel except in emergencies. They did not at the outset have a link obstetrician. This led to fear of burn out, a sense of isolation and lack of support and collegiality. When they transferred babies to the Hospital Birthing Centre, they were expected to refer to a duty obstetric consultant, access to whom was described as variable. The midwife in charge of the NHS unit agreed that she provided a different threshold of care to private and NHS mothers and was reluctant to intervene or review the care plan for augmentation of labour, which she would have done in an NHS patient. The midwives expected her to be involved but did not ask her. In the event no peer senior midwife or obstetrician saw ████████ which was necessary. The reasons for non referral were complex and were not because the midwives thought they could not refer. Misjudgements were made which in part were caused by a 15 hour shift with only a 40 minute break. This would not occur in contexts where there was normal NHS management of staff, but this arrangement continued apparently unknown to the NHS Trust management. The service is no longer operational, the Trust reporting that it was discontinued for economic reasons. Expert advice considered that the model of service created a risk of deaths, although it was not found to have directly done so in this case. Dr ████████ reported that there were similar units operating elsewhere in the country and that the lessons from the difficulties in operating this one should be disseminated to other such units. The expert midwife, Ms ████████ was particularly concerned about adequate support and Dr. ████████ was particularly concerned about the isolation and professional culture and lack of interdisciplinary peer discussion, in the context of increasingly risks in obstetric and midwifery practice. The Trust head midwife reported that she expected that the matter would now be dealt with robustly by the statutory supervision system. No evidence was heard about whether this was now effective in this regard, nor how influence and information could be brought to bear on those setting up or managing such midwife led services. It was further reported that not all midwives are members of the College that runs that supervision and that midwives are not necessarily practising within the NHS. Thus is it was not clear how the risks are best identified and managed across a complex mixed health economy, which is why the Secretary of State is an addressee of my report. ”

    Source location

    Arthur Brockett-Deakins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The private midwifery-led service model was discontinued and no longer operates, so further action on that model is not indicated.

    Verbatim wording from the response

    “As the NMC has already suggested, this is more appropriately addressed by my department. The model of midwifery provision described in this case was and is unacceptable and, for the reasons cited in the Regulation 28 Report, unsustainable. When this incident occurred in 2007 the Trust had a system of two midwives providing care to private patients who requested midwifery-led care. This system was discontinued in July 2010 and no longer operates. The model is not known to exist elsewhere in England.”

    Source location

    2014-0077-Response-by-Department-of-Health
    Page 2 · response
    Published 25 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026