Patient Story
At UHMBT, we live and breathe a woman’s right to choose. Supporting informed, safe and personal choices in maternity care is central to our values and embedded in our practice.
Whether a woman chooses to give birth at home, in a freestanding or alongside midwifery unit, or in an obstetric unit, we are committed to ensuring that all four birth settings are available and respected.
We work in partnership with women and families to explore options and uphold their legal right to choose where and how they give birth. Our maternity teams actively promote shared decision-making, especially for women with uncomplicated pregnancies. We provide open discussions about home birth, including safety evidence, practical considerations and contingency planning. Our midwives and community teams offer personalised support, and our Standard Operating Procedure ensures safe staffing and cross-Bay coordination to protect home birth availability.
In the Public Board Meeting, Chantelle Winstanley, Consultant Midwife for UHMBT, shared the story of Holly, a second-time mum, who experienced a powerful home birth experience, offering valuable insights for colleagues across the Trust.
After a positive first birth at Helme Chase at Westmorland General Hospital in Kendal in 2022, Holly explored all the options and eventually decided on a home birth for her second child. While she initially dismissed the idea of home birth, Holly later embraced it, drawn to the comfort and continuity of midwifery-led care.
On the day of labour, Holly was informed that initially no midwives were available due to staffing pressures. With no transport or childcare, she remained at home and prepared to freebirth. Fortunately, midwives became available later in the day and arrived to support Holly through a safe and empowering birth.
Holly’s story highlights the importance of clear communication, robust on-call systems and respecting women’s choices. Her experience also reflects the evidence supporting midwife-led care for uncomplicated pregnancies, including lower intervention rates and improved maternal outcomes. She praised the attending midwives for their calm, supportive approach, saying: “They weren’t pushy. They let things unfold in our time.”
Holly’s message to colleagues is clear: home birth can be a safe, positive option when supported by informed choice and responsive care. Her story is an important reminder of the importance of personalised care and the need to ensure all birth settings are accessible, reliable and safe.
Chair’s Report
Andrew Stephenson CBE, Chair of the Trust, praised colleagues across UHMBT for their response to the train derailment at Shap on Monday 3 November. Andrew said many colleagues had turned up early having heard the news, but thankfully nobody needed treatment. He said he was incredibly proud of colleagues’ efforts and it was a huge team effort, demonstrating the robustness of the Trust’s Major Incident Plan.
Andrew also highlighted a period of significant engagement, leadership transition and continued progress in his report. Despite national challenges facing the NHS, including financial pressures, winter demands and industrial action, Andrew praised the resilience of the Executive Team and welcomed the Trust’s inclusion in the Neighbourhood Health Implementation Programme. Andrew thanked outgoing Chief Executive Aaron Cummins, who moved on from the Trust to the Lancashire and South Cumbria Integrated Care Board on 31 October. Scott McLean has now taken up the Interim Chief Executive role and recruitment for the substantive post of Chief Executive is underway.
Interim Chief Executive’s Report
Scott McLean presented his first Public Board Report as Interim Chief Executive and updated on several areas including:
- Engagement sessions with the ICB on the future provision of Level Three care at FGH ICU
- Third highest level of flu vaccination amongst staff across the NHS
- Provider capability report being prepared – a self-assessment of how the Trust is performing
- Expansion of Same Day Emergency Care (SDEC) services at RLI and FGH that have led to faster specialist access and reduced admissions
- Awaiting CQC reports on Maternity and Urgent and Emergency Care
- ‘Our Story 2025/26’ sessions launched; new maternity reporting format (AAA) starts January 2026
Lead Governor Update
Suzie Hayman, Lead Governor updated on several issues on behalf of the Council of Governors, including:
- Concerns about the ICU at FGH continue, especially from colleagues and constituents in Barrow. Governors are attending ICB meetings to represent these views
- The Annual Members Meeting was held online in September, resulting in higher attendance than previous years. Discussions are ongoing about reintroducing in-person meetings next year
- Plans are being developed to restart public governor constituency meetings, with bi-monthly sessions proposed to improve engagement
- Her participation in Conflict Resolution, Enhanced Care Planning and Digital Champion that she felt would be of use to Trust colleagues
Maternity Services Update
Susan Foyle, Director of Midwifery, updated the Trust Board on safety, quality and performance in maternity and neonatal services. Key updates from Susan included:
- Our commitment to safe, effective and compassionate care, with 100% compliance in one-to-one labour support and supernumerary labour ward coordinators
- The development of midwifery continuity of care, supported by new funding and set to pilot in early 2026
- Workforce pressures persist, with fill rates averaging 89% at RLI and 84% at South Lakes Birth Centre, though recruitment efforts are underway
- Service user engagement remains strong, with co-designed resources in development to improve informed choices around induction of labour
- The continued monitoring of clinical incidents, with postpartum haemorrhage (PPH) and induction delays flagged for improvement. Despite these, stillbirth and neonatal death rates remain below national averages
- The Maternity Incentive Scheme (Year 7) Safety Action 9 requires Trusts to provide the Board with clear oversight and assurance regarding maternity and neonatal safety and quality issues. A new reporting format using the Assure, Advise, Alert (3A) model is planned for January 2026, aiming to enhance transparency and governance.
Performance and resources
(based on August 2025 data unless otherwise stated)
Quality and Safety
- Complaints closed within 60 days - Target is failing and in common cause variation. However, no complaints have exceeded six months. The focus is now on complaints over five months.
- Mixed sex accommodation (MSA) breaches - 32 breaches in August (11 at FGH, 21 at RLI), mainly due to ICU transfers and lack of side rooms. Discharge delays from ICU are linked to patient flow issues.
- Venous thromboembolism (VTE) assessment compliance - August compliance at 76.1%, slightly up from 75.7% in July. The VTE Improvement Programme is ongoing with strong clinical engagement.
- Inpatient falls - 86 falls in August (up from 79 in July). Sixty resulted in no injury, 25 with low harm, one with moderate harm (fractured neck of femur).
- Patient Safety Incidents (PSI) with moderate or above harm - 30 PSI Investigations commissioned; 10 completed, 16 overdue. All have a designated learning response lead.
- Inpatient pressure ulcers - 47 Category 2 and three Category 3 pressure ulcers
- Summary Hospital-level Mortality Indicator (SHMI) - Increased from 108 to 113. This is not due to increased observed deaths, but a significant reduction in expected deaths, attributed to coding issues
- SHMI Red alerts - Four red alerts originally (fractured neck of femur, Chronic obstructive pulmonary disease - COPD, bronchiectasis and one additional). Two further red alerts have since been added.
- Mortality Reviews - Ongoing reviews show no avoidable deaths. The volume of reviews is becoming unsustainable due to the increased number of alerts. Prioritisation of coding and review processes underway.
- Four-hour Emergency Department (ED) performance - 75.3% against a target of 78% Tactical and strategic UEC cells established - GIRFT (Getting It Right First Time) recommendations being implemented
- 12-hour ED breaches - 5.9% against a target of no more than 2%
- Criteria to Reside - 26.6% against a target of 5% which is a significant challenge
- RTT (Referral to Treatment) 18 week performance: 67.4% against a target of 75.1% - second quartile nationally; third in healthcare peer group
- 65-week waits - Four patients (due to patient choice, late referrals, or validation).
- Wait to first appointment: 75.8% waited 18 weeks (target: 84%).
People
- Vacancy % - Vacancies in September 2025 are reporting at 21.43%
- Appraisal compliance - 70.9% against a target of 85%. Each Division has committed to plans to improve appraisal compliance
- Staff survey initial rate above NHS average in first four weeks.
- Flu vaccination programme - UHMBT is the third best in England for colleague flu vaccination at the time of reporting, briefly reaching second-best
- Our Occupational Health service underwent a national accreditation process in September, with verbal feedback highlighting exemplary practice
- The Trust received two awards: North West winners for Team Placement of the Year An award for our programme supporting students with learning disabilities in collaboration with local colleges
Resources
- At Month 6, the Trust is reporting a £10.8m deficit which is £5.3m adverse to plan. The in-month position was a surplus of £0.1m, £0.6m less than the planned surplus
- To support delivery of the Financial Plan, the Trust has created an internal turnaround process, with a specific focus on tightening authorisation limits and maximising the use of available resources, by daily executive oversight and enhanced grip and control
- The Trust is currently forecasting a mitigated, risk adjusted, deficit of £4.2m at the end of the financial year - against a plan of breakeven
Safeguarding Annual Report
The Safeguarding Annual Report, covering October 2024 to September 2025, was presented by Liz Thompson and Jane Heath, joint Heads of Safeguarding for UHMBT, and provided assurance that statutory safeguarding duties are being met across adults, children, maternity and care leavers. Key highlights included:
- Deprivation of Liberty applications increased by 13% (average of eight per day), reflecting rising patient acuity
- Active participation in Mental Health Enhanced MDTs for patient support and statutory compliance
- 51 colleagues were supported via Health Independent Domestic and Sexual Violence Advisors
- Digitised hospital passports now integrated with electronic patient records for improved continuity of care
- 392 vulnerable families were supported, including 33 babies born under Child Protection Plans, 12 babies separated due to local authority intervention and nine babies born to mothers affected by Female Genital Mutilation
- Improved child death response with new guidelines and key worker roles
- Ongoing support for children facing criminal and sexual exploitation via specialist nurse leadership
Provider Collaborative update
Scott McLean presented the Provider Collaborative Board (PCB) update. This included the launch of a national frailty collaborative aimed at improving care for the region’s 380,000 plus over-65s, half of whom have a frailty score. This initiative will integrate services across health, social care and the voluntary sector to deliver person-centred care.
Acute clinical service reviews continue, with six specialties - Stroke, Vascular Surgery, Urology (Cancer), Head and Neck (Cancer), Orthodontics and Gastroenterology - under active reconfiguration.
Governance reform is underway, with the PCB endorsing a Lead Provider model for One LSC to streamline decision-making and accelerate change. Financial pressures persist, with providers reporting a £58.1m year-to-date deficit, though collaborative portfolios are forecast to deliver £11.7m in benefits.
Mental Health Urgent Access Centres are being re-evaluated in favour of dedicated Mental Health Emergency Departments, aligning with the NHS 10-year plan. Hospices also received strong support for increased funding to sustain vital services.
Research and Development update
Helen Skinner, Chief Medical Officer delivered a Research and Development Update outlined a clear and ambitious vision for the Trust’s future as a research-active organisation. Helen emphasised that embedding research into everyday clinical practice is not only vital for innovation but also directly linked to improved patient outcomes. The Trust is currently ahead of target in research recruitment, a positive sign that both patients and staff are increasingly engaged in research activity.
Helen highlighted the need to broaden the scope of research beyond clinical trials. She welcomed the idea of exploring areas such as workforce transformation, estates planning and data-driven service improvements. This aligns with the Trust’s existing partnerships with Lancaster University and the University of Cumbria, which offer opportunities for interdisciplinary collaboration.
A key focus of the update was the development of a secure data platform across Lancashire and South Cumbria. This infrastructure will support the safe sharing of anonymised data for research, backed by appropriate governance and data-sharing agreements. Helen concluded by reaffirming the Trust’s commitment to expanding research opportunities and ensuring that more patients and staff can participate.
Provider Capability Self-Assessment
The Trust Board considered the NHS Oversight Framework’s Provider Capability Self-Assessment. Led by the Governance and Assurance Team, the process asks: “Does the Board know its business, and does it understand what’s happening within the organisation?” The assessment focuses on six key areas, including strategic leadership, quality of care, people and culture and system collaboration.
Through open and honest dialogue between executive and non-executive directors, the Trust evaluated its strengths and areas for improvement. While robust systems and processes were acknowledged, particularly in quality assurance and patient experiences, challenges such as financial pressures, digital strategy alignment and workforce capacity were candidly discussed.
The Board recognised the importance of institutional memory, with internal leaders stepping into interim roles, ensuring continuity and insight. The assessment was not just a compliance exercise but a mirror reflecting the Trust’s commitment to transparency, learning and improvement.
The self-assessment will be submitted to NHS England who will triangulate what has been said against other metrics and data before sharing a final outcome in early 2026.
Other reports considered
- Audit Committee Report
- People Committee Report
- Finance and Performance Committee Report
- Quality Assurance Committee Report
- Transformation and Improvement Board
- Health and Safety Annual Report
- NHS England 10 Point Plan to Improve Resident Doctors’ Working Lives
- Board Assurance Framework 2025/26
- Trust consultation - Review of appointed governors
These reports can be accessed as part of the 5 November 2025 Board of Directors meeting agenda.
Next meeting: Wednesday 7 January 2026 at 9am in the Board Room, Westmorland General Hospital, Kendal LA9 7RG, via Microsoft Teams.
If you have any feedback on this briefing, please let us know by contacting the Corporate Communications Team on: communications.team@mbht.nhs.uk.