Maternity services at a trust which are the subject of the largest inquiry of its kind in NHS history still require improvement and « did not always keep women and their babies safe », inspectors have said.
The Care Quality Commission (CQC) carried out unannounced inspections of Nottingham City Hospital and the Queen’s Medical Centre (QMC) in May last year, where they found « gaps » in staffing.
While noting women « were treated with kindness and compassion », a « requires improvement » rating was given, the same as last year.
Nottingham University Hospitals (NUH) NHS Trust, which runs the hospitals, said it « remains committed to continued improvement in its maternity services ».
Following dozens of baby deaths and injuries at the trust, NUH’s maternity services are currently the subject of the biggest review of its kind in the NHS, with about 2,500 cases being examined.
It is being led by senior midwife Donna Ockenden, and is due to conclude later this year.
In its latest reports, published on Wednesday, the CQC said some women « expressed concerns about receiving their maternity care in a service that was under so much scrutiny due to the well-publicised historical failings in care » – but the report added people « had positive experiences of the care they received and praised the staff for their kindness ».
Inspectors said hospital management « did not always support staff well-being » and « were not always visible within the service and were sometimes perceived as unsupportive ».
« Staff reported they were confident to report incidents, however, were not always assured action would be taken, » the CQC report said.
« Some staff we spoke with expressed a perception that, during incident investigations, a culture of assigning blame was present. »
Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were also found in relation to security, governance and staffing.
The CQC reports also said there were « continued breaches in relation to baby and infant abduction » policies, with staff unaware of when a test for a possible abduction incident had taken place.
Inspectors also found « a lack of system and process to check the identification bands of both mother and baby if they were separated », and « saw evidence » of an incident in which a baby was returned to the wrong mother.
Anthony May, chief executive at NUH, said: « We are grateful for the feedback from the CQC following the inspection in May 2025 and have taken action to address the areas that they identified for us to improve.
« We can assure the public and our staff that we take concerns around safety, leadership and security seriously.
« Since the inspection report, we have created additional ways for staff to give feedback and discuss learning. »
May said midwifery staffing had improved and the trust was committed to increase obstetrician staffing.
« We have reviewed our security policies in response to the feedback, and have completed safety drills at both sites to test our abduction policy.
« The report highlights 97% positive feedback in our friends and family test, with patients having ‘nothing but praise’ for our staff, explaining that they were treated with kindness and compassion.
« I should like to thank our staff for their hard work, often in difficult circumstances. I should also like to thank the women and families that use our services for their invaluable feedback, » he added.
By Rob Sissons, East Midlands health correspondent
The great flaw in the latest watchdog reports on the state of Nottingham’s maternity units is that it is a somewhat dated snapshot of the service – both campaigning families and staff at the trust find this frustrating.
Inspections were carried out almost a year ago in May 2025 and have only been published 10 months later, and the reports themselves give no detailed insight into what has changed since.
The CQC told me it accepts that the timescale is not optimum, but says it has to balance speed and the importance of getting comprehensive findings right.
Its reports make for some mixed reading – the ongoing improvement plan is acknowledged, but in reality the service is still not where it needs or wants to be.
One of the most eye-catching parts of the inspection is the security lapses to protect babies, with the report saying leaders had not carried out a drill to go over what to do if a baby was abducted.
Such a scenario may seem unlikely, but I need no reminding that it is possible. I was on duty as a reporter at BBC Radio Nottingham in July 1994 when I took a call from the police that a three-hour-old baby had been stolen from the Queen’s Medical Centre, a case that was global news.
Thankfully, baby Abbie Humphries was found just over two weeks later and returned to her mother, but the case is a stark reminder of how the unexpected can happen, and how hospital security matters.
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