Maternity Services Review & Improvement Plan
Following the appointment of Dr Gillian Fairfield as the Trust’s new Chief Executive in April 2014, and prior to a full review of the Trust’s serious incident policy and processes, a system was introduced whereby all SUIs (serious untoward incidents) were notified to the Chief Executive and Executive Directors within 24 hours and discussed at the Senior Management Team (SMT) on a weekly basis. This ensured the Trust could take any immediate corrective action required and reduce risk.
This new process highlighted several incidents within maternity services. The incidents reported were reviewed through the Trust’s own root cause analysis and serious incident processes and any immediate improvements or actions required were implemented. However, to ensure that we left no stone unturned we commissioned an independent external review of nine incidents which had occurred within maternity services.
The terms of reference for the review were agreed by the SMT and the Trust Board of Directors.
In summary, the findings of the external review were:
- The population of women cared for at Pennine Acute Trust is diverse and challenging and includes a significant number of high risk and vulnerable women.
- There are clearly areas of good practice which are appropriately noted and acknowledged and which should be widely shared.
- The three maternal deaths did not appear to be the result of deficiencies in care.
- The serious incidents were thoroughly and comprehensively reviewed by the Trust and there was a clear, honest and open approach to identifying failings.
However, while many of the areas identified for improvement by the external reviewers had already been addressed in the findings and recommendations of the Trust incident panels the external reviewers recommended that further scrutiny and improvement was required in the following areas:
Clinical Risk Management:
In some cases risk management during the antenatal period and in labour were below standard which may have contributed to the poor outcomes
In a number of the cases reviewed there had been a notable absence of clinical leadership in both medical and midwifery teams resulting in failure to plan care.
Obesity which was evident in a number of cases was not managed in line with local or national guidance.
Serious Incident Investigations:
While the incidents were reviewed in line with trust policy and in an open and honest way the root causes were not always clearly defined, learning points were not always addressed and some recommendations were vague.
There were twelve recommendations made within the review - click here to view the recommendations.
Publication of External Review Report & Improvement Plan - 25 June 2015
The Pennine Acute Hospitals NHS Trust Board discussed the report of the external review of maternity services that was commissioned in 2014. In order to maintain our duty of patient confidentiality individual patient details have been removed from the external review report. The Board also discussed the improvement plan which responded to the recommendations in that review, and also took account of other recent national reports.
The Trust Board today repeated sincere apologies to all of the families involved for the failings in care which had been identified. Gill Harris, Chief Nurse has met with a number of the families and has reiterated the offer to meet with the remaining families, if they wish.
The Trust commissioned review looked at 10 incidents which had occurred within maternity services over the period Jan 2013 and July 2014. These should be seen in the context of approximately 10,000 births a year at The Royal Oldham Hospital, North Manchester General Hospital and including home births.
The Trust has shared the external review report and the improvement plan with the families involved and has kept in touch with those families, arranging meetings and discussions depending on individual wishes. The report and improvement plan has also been widely shared with partner organisations. Implementation of the improvement plan has been overseen by a group comprising of senior Trust staff and senior representatives of local Clinical Commissioning Groups and the Trust Development Authority; NHS England and the Care Quality Commission have also been involved in overseeing the work undertaken.
Improvement Plan Updates