There were twelve recommendations made within the review, which are outlined below:
- Staffing issues where safety is compromised must be appropriately escalated, and must include involvement of the duty Supervisor of Midwives.
- Managers must ensure that the process for escalating concerns is clear.
- The process for employing and managing locum doctors should be reviewed.
- The directorate should review its management of obesity in pregnancy, labour and the postnatal period, and that guidelines are appropriately implemented.
- All serious incident reports should be ‘quality checked’ before submission, to ensure that the root cause clearly established.
- Recommendations made by the serious incident review panel must be clear and unambiguous.
- Where individual failings have been identified, the reports must demonstrate that training / educational needs have been considered.
- Senior managers must ensure that training / educational needs are addressed where leadership has failed.
- Serious incident reviews must be signed off by a nominated senior manager from the appropriate specialty.
- The directorate should ensure that all mandatory training is up to date for all disciplines of staff, including record keeping and interpretation of CTG.
- All available methods should be used to ensure that standards of documentation are improved where necessary.
- The Trust must be assured that a robust system is in place to ensure the regular and timely review, implementation and audit of guidelines in accordance with Trust policy.
The Care Quality Commission produces data on perinatal mortality ratios. The CQC’s latest analysis shows the Trust is not an outlier for perinatal mortality rates and that perinatal mortality ratios at the Trust are similar to expected.