North Devon District Hospital

⚠ Staff did not always have access to standardised risk assessment tools for telephone triage or in-person triage, relying on individual clinical judgement. There was no formal risk assessment tool for maternity triage, and no dedicated call handling system or monitoring of call drop-off rates. Leaders and staff did not monitor …

⚠ Staff did not always escalate concerns when there were signs of deterioration. An audit showed only 50% of Modified Early Warning Scores (MEWS) charts were completed and 50% of women with abnormal scores were escalated correctly. Fresh eyes monitoring for fetal monitoring was not consistently completed in accordance with best …

⚠ 504 out of 513 red flag incidents over 12 months were reported as delays in continuation of induction of labour, indicating insufficient staff to manage inductions safely. Induction of labour processes were not routinely reviewed to ensure women could access care within an appropriate timescale.

⚠ Compliance for level 3 safeguarding adults was not received for medical staff, meaning the trust could not be assured medical staff had the appropriate skills to safeguard vulnerable adults.

⚠ Leaders did not operate effective governance systems, manage risk, issues, and performance well, or consistently monitor the effectiveness of the service. The approach to service delivery and improvement was reactive, and the audit systems were inconsistent in implementation and impact, limiting effective planning and risk management. The local audit programme …

⚠ Staff did not always recognise and report all incidents, with discrepancies in reporting data (e.g., perineal repair delays). A MEWS audit showed only 25% of escalations were correct, but no related incidents were reported. The service had not always made effective changes following incidents. Initial 72-hour reviews were not clearly …

⚠ Staff did not have access to up-to-date policies, with 91 of 234 policies reported as out of date, reducing their ability to plan and deliver high quality care according to evidence-based practice and national guidance.

⚠ The service did not actively monitor and report red flags involving ward coordinators’ supernumerary status. On the day of inspection, the coordinator was not supernumerary and worked clinically, impacting their ability to monitor and respond to staffing pressures, acuity, and capacity.