Maternity services at Bedford Hospital and Luton and Dunstable University Hospital have again been rated inadequate by the Care Quality Commission (CQC), after inspectors found only limited progress had been made since the services were downgraded in 2023.
Both hospitals are run by Bedfordshire Hospitals NHS Foundation Trust and are used by families across Bedford Borough and the wider region.
Unannounced follow-up inspections were conducted in June and July last year to determine whether earlier concerns had been addressed.
The CQC said minimal improvements had been made and that both services remained in breach of regulations on staffing and management, with new breaches identified in relation to safe care and treatment.
As a result, maternity services at both hospitals remain rated inadequate overall and in terms of safety and leadership. Ratings for other areas are unchanged, with caring rated as good and effective and responsive both require improvement.
Staffing, unanswered calls and incident backlogs
Carolyn Jenkinson, CQC deputy director of hospitals in the East of England, said inspectors were “deeply concerned that improvements in maternity services were happening too slowly, with little change since our previous inspection”.
She said low staffing levels were having the biggest impact on women’s experiences, including delays in accessing services and reduced choice.
At Bedford Hospital, CQC found the maternity triage service was frequently understaffed.
Inspectors said that between January and June 2025, 451 of 2,097 calls went unanswered or were abandoned by callers due to wait times, putting women at risk of not receiving the care they needed.
They also found the elective caesarean section service at Bedford had been paused 32 times over a six-month period because there were not enough staff to support women who did not require emergency care.
At Luton and Dunstable Hospital, women experienced delays to elective caesareans and induction of labour, and there were frequent diversions to other hospitals due to staffing shortages.
The CQC said staff at Luton and Dunstable reported that low staffing levels were affecting morale, contributing to sickness absence and, in some cases, leaving them feeling unsafe at work.
Inspectors also raised serious concerns about incident management and learning. At Luton and Dunstable, more than 1,500 incidents were open at the time of the inspection, with over 1,100 overdue for investigation or closure.
Across both sites, some incidents had remained open for more than 60 days.
Training, policies and safety standards
Across both hospitals, the CQC found:
- Staff did not always assess risks to people’s health and safety or act to reduce them once identified.
- There were significant backlogs of incidents awaiting investigation, and learning from incidents and complaints was not consistent.
- Not all staff had completed mandatory training, with particular concerns about medical staff completing safeguarding and emergency training.
- Many policies and clinical guidelines were out of date, including those covering baby abduction, post-partum haemorrhage and sepsis management.
- The trust was not complying with five of the ten safety actions in the national maternity incentive scheme for 2024/25.
Despite these concerns, inspectors said women described staff as attentive and respectful of their privacy and dignity, and reported overall positive experiences of care.
They also noted that women were able to feed back through the local maternity and neonatal voices partnership, which regularly reports to the trust.
Ms Jenkinson said: “We have shared our findings with the trust and will continue to monitor these services closely, including through further inspections, to ensure improvements are delivered quickly, and people are kept safe.”
Trust apologises
In a statement, Bedfordshire Hospitals NHS Foundation Trust said it accepted the CQC’s findings and apologised where care had not met the standards “our community rightly expects”.
The trust noted that the CQC had also heard positive feedback from women, who reported “high quality, compassionate and responsive care” and said midwives were attentive and respected their privacy and dignity, but acknowledged this was not being delivered consistently.
“Women and babies deserve consistently safe, high-quality care,” the trust said.
The trust said that since last summer’s inspection, maternity teams at both sites, supported by colleagues across the organisation, had delivered “significant improvements” focused on staffing, staff development and estates.
Changes include:
- Staffing and clinical cover: a dedicated telephone triage midwife and a private triage area at Bedford Hospital; Acute Care Oversight consultants providing daily senior oversight on the labour ward at Luton and Dunstable; extended Day Assessment Unit opening hours at Luton and Dunstable (7am to 7.30pm).
- Staff development and wellbeing: wellbeing check-ins; co-production of a new Anti-Racism and Incivility Charter; work with the Nursing and Midwifery Council to provide professional behaviours training; and more flexible access to mandatory and maternity-specific training, including PROMPT, fetal monitoring and maternity support worker development.
- Estates and facilities: moving maternity services into the new Acute Services Block at Luton and Dunstable (Cedar and Oak Wings), creating modern, purpose-built spaces; and opening community maternity hubs in Bedford at Queens Park and Pine Cones to improve access, privacy and choice.
The trust has also introduced a “mini-switchboard” phone system in the Bedford triage and a multi-language online discharge pack, co-produced with the Maternity Neonatal Voices Partnership, to support communication and safety.
David Carter, chief executive of Bedfordshire Hospitals NHS Foundation Trust, said: “As a Trust committed to delivering excellent care, the latest CQC inspection rating for our maternity services was disappointing for us to hear…
“But we remain focused in our effort on ensuring that our maternity services consistently meets the standards of care we aspire to give.
“We are sorry where care has not met the standard our community rightly expects, and our leadership teams will continue to work hard in removing obstacles to allow our maternity colleagues to provide the best care.
“Since last summer’s inspection, we have strengthened staffing and senior clinical oversight, expanded staff development and wellbeing support, and opened state-of-the-art maternity facilities in our new Acute Services Block at the L&D.
“At Bedford, we’ve introduced a dedicated telephone triage midwife, new ‘mini switchboard’ phone triage service and a private triage area to improve access, privacy and dignity. We will keep our community updated as we deliver further improvements.”
National maternity review
Bedford Hospital’s maternity services were first rated inadequate by the CQC in 2023, with inspectors raising concerns about leadership, midwife staffing and care planning.
Read: Mohammad Yasin MP presses minister on Bedford Hospital maternity downgrade in Parliament
Following that downgrade, Bedford and Kempston MP Mohammad Yasin raised the issue in Parliament in September 2025, highlighting the impact on local birthing choices, including the reduction of the homebirth service.
Speaking in the House of Commons at the time, he called on ministers to ensure that the new national review of maternity and neonatal care, led by Baroness Valerie Amos, examined why choices for birthing services were being cut and delivered improved outcomes for mothers and babies.
Responding, Health Minister Stephen Kinnock said the national investigation would look at “systemic issues” in maternity services and confirmed that the CQC would continue to monitor Bedford closely while improvements were made.
The Amos Review is expected to produce national recommendations to address long-standing concerns over safety, leadership and quality of care across NHS maternity and neonatal services.
The CQC says it will continue to monitor maternity services at both Bedford Hospital and Luton and Dunstable University Hospital, including through further inspections, to check that Bedfordshire Hospitals is delivering the improvements set out in its action plan.
The reports for Bedford Hospital and Luton and Dunstable Hospital will be published on CQC’s website.
