Cause for Concern Process · pathway care S Smith G Gold SWHMR Pregnancy Record Good continuity of...

Cause for Concern Process

Guidelines for Supervisors of Midwives

North of Scotland Local Supervising Authority Consortium

2

Guideline produced by: Supervisors Quality Improvement Group (SQIG)

Guideline production date: Version 1: May 2009

Version 2: January 2013, updated August 2013

Consultation process: North of Scotland LSA Consortium

Draft reviewed by: Supervisors Quality Improvement Group

Guideline approved by: North of Scotland LSA Consortium

Guideline approval date: 26/08/2013

Guideline Implementation date: 01/09/2013

Guideline review date: January 2016

Paper copies of this guideline may not be the most recent version. The definitive version is

held at http://www.midwiferysupervision-noslsa.scot.nhs.uk

3

Contents

Introduction ............................................................................................................................ 4

Process.................................................................................................................................. 5

Local Action Plan ................................................................................................................... 6

Outcome ................................................................................................................................ 6

References ............................................................................................................................ 7

Appendix 1: Cause for Concern Flow Chart ........................................................................... 8

Appendix 2: Cause for Concern Form .................................................................................. 10

Appendix 3: Supervisory review/fact finding event chronology ............................................. 13

Appendix 3a: Example of supervisory review/fact finding event chronology - no concerns-

good practice identified .................................................................................................... 15

Appendix 3b: Example of supervisory review/fact finding event chronology - SoM

investigation not recommended but some issues identified .............................................. 18

Appendix 3b: Example of supervisory review/fact finding event chronology - SoM

investigation recommended .............................................................................................. 21

Appendix 4: Local Action Plan ............................................................................................. 24

Appendix 4a: Example of a Local Action Plan .................................................................. 25

4

Introduction

Local Supervising Authorities (LSA) are organisations within geographical areas, responsible

for ensuring that statutory supervision of midwives is undertaken according to the standards

set by the Nursing and Midwifery Council (NMC) under article 43 of the Nursing and

Midwifery Order 2001, details of which are set out in the NMC Midwives rules and standards

(NMC 2012). In Scotland, the function of the LSAs is provided by the Health Boards, which

are arranged into two Regions: the South East and West of Scotland and the North of

Scotland.

Each LSA has an appointed LSA Midwifery Officer (LSAMO) to carry out the LSA function.

The LSAMOs are practising midwives with experience in statutory supervision and provide

an essential point of contact for Supervisors of Midwives to consult for advice on aspects of

supervision. Members of the public who seek help or support concerning the provision of

midwifery care, can also contact the LSAMO directly. LSAMOs provide leadership, support

and guidance on a range of matters including professional development. They also

contribute to the wider NHS agenda by supporting public health and interprofessional

activities at Health Board level.

The Supervisor of Midwives role includes supporting midwives to develop and improve their

practice. This includes giving advice to individual midwives and/or their employers when

additional support is needed for a midwife to ensure safety for the public. For example when

a midwife

� Needs support to learn a new skill or role required for the employment

� Needs to orientate to a new organisation or department

� Has returned to the workplace after an absence and needs support to gain

confidence

� Has requested additional support to aid personal or professional development

� Has identified a problem with their own practice that they need support with

� Has made a minor mistake, with little or no risk of recurrence

Such circumstances can be corrected through a local action plan with the named supervisor

of midwives. This may include reflection on an incident or undertaking continuing

professional development relevant to the issue that caused concern.

5

The purpose of this guideline is to help Supervisors of Midwives determine when and how to

initiate the cause for concern process and when to escalate to the LSA via the LSAMO.

Raising a Cause for Concern by Supervisors of Midwives

Raising and communicating a cause for concern should primarily be viewed as a positive and

supportive procedure for the midwife concerned and an area where the primary focus of

support will be through the supervisory structure.

It is better to report an issue of concern early, waiting and hoping for an improvement may

delay effective intervention. The process should be used to structure feedback and monitor

the midwife’s progress.

The process is outlined below and summarised in appendix 1.

Process

A cause for concern should be initiated if following discussion between a midwife and her line

manager and or a Supervisor of Midwives there is no resolution regarding her

� competence

� conduct

� involvement in a clinical incident

The initiation of the cause for concern must be communicated to the midwife, her named

Supervisor of Midwives and her line manager/ team leader.

A review of the concerns raised will be undertaken by the midwife’s named Supervisor of

Midwives, or if this is not possible, another Supervisor of Midwives within the area. At this

stage a cause for concern form should be commenced (appendix 2).

If the cause for concern involves a clinical incident a supervisory review/fact finding event

chronology (appendix 3) should also be completed to determine whether a supervisory

investigation is required. If it is determined that a supervisory investigation is not required but

6

the midwife (s) has made a minor mistake, with little or no risk of recurrence then the cause

for concern process should be followed and a local action plan put in place.

In order to ensure the process encourages reflection on practice and maintains the purpose

of a supportive intervention it is imperative that midwives receive feedback via letter or email

when care and support has been found to be effective, appropriate and safe following a

critical incident.

Local Action Plan

The named Supervisor of Midwives needs to ensure that the midwife receives the necessary

support to enable, where possible, an early resolution to the situation. This might include the

following

� review of shift patterns

� review of work environment

� occupational health referral

The Supervisor of Midwives will meet with the midwife to discuss with her the concerns

raised and agree a local action plan and regular feedback times and review dates (appendix

4). It is expected that the midwife, will demonstrate that she has successfully achieved the

competencies/objectives set in the local action plan within 4 weeks of commencement.

Outcome

Once a local action plan has been put in place the Supervisor of Midwives should inform the

LSAMO of the cause for concern and progress made by the midwife.

Possible outcomes that will result from the local action plan are as follows

� cause for concern resolved – no further action required

� cause for concern unresolved

� repeated concerns raised

7

If the cause for concern remains unresolved or repeated concerns arise about the midwives

competence and/ or conduct the Supervisor of Midwives will write a report and forward this to

the LSAMO for guidance and advice about the next steps to be taken.

It is important to note that where a cause for concern involves a serious untoward clinical

incident, intractable incompetence or serious misconduct a supervisory investigation must be

carried out in accordance with the LSAMO Forum UK guideline Supervisory Investigation into

a midwife’s fitness to practise (appendix 1).

References

LSAMO Forum UK 2013 Supervisory Investigation into a midwife’s fitness to practise.

Available online @ http://www.lsamoforumuk.scot.nhs.uk/policies-guidelines.aspx

Nursing and Midwifery Council 2012 Midwives rules and standards. London: NMC

The Nursing and Midwifery Order. SI 2002 No. 253. Available online @

http://www.opsi.gov.uk/si/si2002/20020253.htm

8

Appendix 1: Cause for Concern Flow Chart

Cause for concern form commenced by SOM

A review of the concerns raised will be undertaken by the midwife’s named SOM or another SOM within the area

Cause for concern communicated to: � the midwife � midwife’s named SOM � line manager/ team leader

SOM initiates and co-ordinates support to seek

resolution

Cause for concern resolved

• LSAMO informed

• local action plan entered on LSA Database

SOM and midwife:

• discuss/ assess cause for concern

• agree local action plan

• agree regular feedback times and review date/s

Implement local action plan LSAMO informed of proceedings

Evaluate progress

Cause for concern unresolved/ repeated concerns raised –

• SOM writes a report and forwards to LSAMO

• LSAMO advises re further action required

Concern raised regarding minor non-recurring issues in relation to competence/ misconduct/ a clinical incident* Following discussion with midwife no resolution regarding concerns raised about

• competence/conduct

• clinical incident

Where a cause for concern regards a serious adverse clinical incident*, intractable incompetence** or serious misconduct*** the LSAMO must be informed and a supervisory investigation carried out

9

*In this context, a clinical incident is any situation that raises concern that the public are being put at risk. However if the incident is serious

please refer to the Monitoring & Reporting Serious Incidents & Events Guideline

** Lack of competence is a lack of knowledge, skill or judgement of such a nature that the registrant is unfit to practise safely and effectively in any field in which the registrant claims to be qualified, or seeks to practise

Examples of lack of competence include:

� persistent lack of ability in correctly and/or appropriately calculating administering and recording the administration or disposal of medicines

� persistent lack of ability in properly identifying care needs and, accordingly, planning and delivering appropriate care

*** Misconduct is conduct, which falls short of that which can reasonably be expected of a registrant.

The most common examples of misconduct include:

� physical or verbal abuse

� theft

� deliberate failure to deliver adequate care

� deliberate failure to keep proper records

10

Appendix 2: Cause for Concern Form

Date Concern Reported

Midwife Involved

Practice Area

Supervisor of Midwives

Undertaking Review

Supervisory review/fact

finding event chronology

YES / NO

If yes attach a copy

LSAMO Informed YES / NO Phone / E-mail / Verbal

Date

If no state reason why

Line Manager Informed YES / NO Phone / E-mail / Verbal

Date

If no state reason why

Overview of cause for concern:

Midwife Signature:

Date:

Supervisor of

Midwives

Signature:

Date:

11

Agreed Action / Process:

Action carried out by:

Midwife Signature: Date:

Supervisor of

Midwives

Signature: Date:

12

Outcome:

Local Action Plan successfully completed

and entered on LSA Database

yes no

Period of review agreed with named

Supervisor of Midwives

yes no

Further action required yes no

If yes please specify action required

LSAMO informed Date

Line manager informed Date

Midwife Signature: Date:

Supervisor of

Midwives

Signature: Date:

13

Appendix 3: Supervisory review/fact finding event chronology

Trigger:

Woman’s Name:

CHI: LSA: Maternity Unit:

Medical/Social history:

Past obstetric history:

Present pregnancy:

Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student

Midwife(s), Medical Staff

involved

Evidence Source Supervisor of Midwives

Commentary

Review of antenatal care provided (please keep brief if nil of note – but highlight good practice)

Review of intranatal care provided (please keep brief if nil of note – but highlight good practice)

Review of postnatal care provided (please keep brief if nil of note – but highlight good practice)

14

Recommend Supervisory Investigation: YES NO

Reason/s for decision:

If good practice has been highlighted, please identify/detail the named SoM(s) below and inform her (them) via letter or email

Informed by letter /email Date:

Signature of Reviewing SoM: Date of review:

Copy of review to LSAMO Date:

Entered on LSA Database YES NO

15

Appendix 3a: Example of supervisory review/fact finding event chronology - no concerns- good practice

identified

Trigger: Haemorrhage

Woman’s Name: B Brown

CHI: 0101790101 LSA: A&B Maternity Unit: Local Royal Infirmary

Medical/Social history: Nil of note

Past obstetric history: Green pathway. SVD at term. Nil of note.

Present pregnancy: Green pathway. Nil of note

Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student


involved


Commentary


070501-

241001

Booking at 13 wks

gest to 40 wk ANC

apt.

Routine antenatal green

pathway care

S Smith

G Gold

SWHMR

Pregnancy

Record

Good continuity of care

Appropriate care

High standard of documentation


271001

0830-1335

Admission in

established labour

Baseline observation

normal. Green pathway

labour care provided.

G Green SWHMR Labour

and Birth Record

Appropriate care planning

Appropriate documentation

271001

1336

SVD Routine care provided.

Active 3rd

stage as

requested.

G Green As above As above

271001

1350

Sudden brisk bleed –

total blood loss

1500mls

IV access sited – FBC,

X Match, Coagulation

screen.

G Green

Dr Gray (Cons)

As above plus

MEWS chart

As above plus

Appropriate escalation

16

Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student


involved


Commentary

Ergometrine IM.

Observations normal.

Medical staff present to

review

271001

1405

Further heavy PV

loss – total blood

loss 2000mls

Ultrasound scan by Dr

Gray-Clots seen in

uterus.

G Green

Dr Gray (Cons)

As above As above

271001

1420

Transferred to

theatre for EUA

Clots removed from

uterus. Haemostasis

achieved. Total blood

loss 3000 mls.

G Green

Dr Gray

As above plus

Anaesthetic chart

As above

271001

1500-

Transferred to

observation area

Post PPH care provided.

All observations within

range of normal.


and Birth Record

MEWS chart

As above

281001

0900

Ward round – Transfer to post natal

ward

G Green

Dr Gray

As above As above plus

Good continuity of care.

Review of postnatal care provided (please keep brief if nil of note – but highlight good practice)

301001-

061101

Care in postnatal

ward & discharged to

home on day 3.

Discharged from

community care on

day 10

Uneventful postnatal

recovery

L Lynch

B Black

T Turner (ST M)

SWHMR Mother

and Baby

Postnatal

Records


Good documentation.

Appropriate care provided

17

Recommend Supervisory Investigation: YES NO X


Good practice identified, good continuity of care and good documentation


D Dunn for G Green, G Gunn for Black & Gold, J Jones for S Smith & L Lynch.

Informed by letter or email Date: 131101

Signature of Reviewing SoM: P Pitt Date of review: 131101

Copy of review to LSAMO Date: 131101

Entered on LSA Database YES X NO

18

Appendix 3b: Example of supervisory review/fact finding event chronology - SoM investigation not

recommended but some issues identified




Medical/Social History: Nil of note



Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student


involved


Commentary


070501-

241001

Booking at 13 wks

gest to 40 wk ANC

apt.


pathway care

S Smith

G Gold

SWHMR

Pregnancy

Record


Appropriate care



271001

0830-1335

Admission in

established labour





and Birth Record

No evidence of care planning

Some gaps in documentation

271001

1336


Active 3rd

stage as

requested.


271001

1350

Sudden brisk bleed –

total blood loss

1500mls

IV access sited routine

bloods obtained

Ergometrine IM.

G Green

Dr Gray (Cons)

As above plus

MEWS chart

As above plus

Appropriate actions taken/appropriate

escalation

19

Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student


involved


Commentary


Medical staff present to

review

271001

1405

Further heavy PV


loss 2000mls

Ultrasound scan by Dr

Gray-Clots seen in

uterus.

G Green

Dr Gray (Cons)

As above As above

271001

1420

Transferred to

theatre for EUA

Clots removed from

uterus. Haemostasis


loss 3000 mls.

G Green

Dr Gray

As above plus

Anaesthetic chart

As above

271001

1500-

Transferred to

observation area

Post PPH care provided.

All observations within

range of normal.


and Birth Record

MEWS chart

As above

281001

0900

Ward round Transfer to post natal

ward

G Green

Dr Gray

As above As above plus


Review of postnatal care provided (please keep brief if nil of note –but highlight good practice)

301001-

061101

Care in postnatal

ward and discharged

to home on day 3.

Discharged from

community care on

day 10


recovery

L Lynch

B Black

T Turner (ST M)

SWHMR Mother

and Baby

Postnatal

Records


Good documentation.


20

Recommend Supervisory Investigation: YES NO X


A SoM investigation is not recommended since appropriate actions were taken and the midwifery care provided was appropriate and in line

with local protocols and current evidence based guidance. However, the documentation does not always reflect this and some entries are not

timed and signed. B Bloggs (named SoM for G Green) has been notified and will discuss documentation and work with G Green to carry out a

self-audit of 3 sets of case notes to address these issues.


G Gunn for B Black & G Gold, J Jones for S Smith & L Lynch





21

Appendix 3b: Example of supervisory review/fact finding event chronology - SoM investigation

recommended




Medical/Social History: Nil of note



Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student


involved


Commentary

Review of antenatal care provided (please keep brief if nil of note –but highlight good practice)

070501-

241001

Booking at 13 wks

gest to 40 wk ANC

apt.


pathway care

S Smith

G Gold

SWHMR

Pregnancy

Record


Appropriate care


Review of intranatal care provided (please keep brief if nil of note –but highlight good practice)

271001

0830-1335

Admission in

established labour





and Birth Record

No evidence of care planning

Some gaps in documentation

271001

1336


Physiological 3rd

stage

despite birth plan

documentation for active

3rd

stage


271001 Sudden brisk bleed – Ergometrine IM. G Green As above plus As above plus

22

Date & time

of event Event

Action(s)

taken/Concern(s)

raised/Care planned

Midwife(s), Student


involved


Commentary

1350 total blood loss

1500mls


No IV Access

Not escalated to medical staff

271001

1405

Further heavy PV


loss 2000mls

Woman feeling unwell.

BP 88/45 P132bpm

Help called for

G Green

Dr Gray (Cons)

As above Documentation inadequate

No MEWS chart

271001

1420

Transferred to

theatre for EUA

Clots removed from

uterus. Haemostasis


loss 3000 mls.

G Green

Dr Gray

As above plus

Anaesthetic chart

As above

271001

1500-2100

Transferred to

observation area with

blood transfusion in

progress

Urinary output

<60ml/hr

Irregular/infrequent

maternal observations

Repeat bloods not taken


and Birth Record

MEWS chart

As above

Failure to obtain blood samples

Failure to escalate reduced urinary

output to medical staff

281001

0900

Ward round – Transfer to post natal

ward

G Green

Dr Gray

As above Inadequate documentation resulting in

substandard handover information to

postnatal ward staff.


Review of postnatal care provided (please keep brief if nil of note –but highlight good practice)

301001-

061101

Care in postnatal

ward and discharged

to home on day 3.

Discharged from

community care on

day 10


recovery

L Lynch

B Black

T Turner (ST M)

SWHMR Mother

and Baby

Postnatal

Records


Good documentation.


23

Recommend Supervisory Investigation: YES X NO


Inadequate/poor care planning

Inadequate/poor documentation

Failure to communicate/escalate to medical staff

Failure to perform regular maternal observations on high risk woman

Failure to obtain blood results


G Gunn for B Black & G Gold, J Jones for S Smith & L Lynch





24

Appendix 4: Local Action Plan

Midwife’s Name: Supervisor of Midwives:

By the end of this Local Action the

midwife will have:

Action Plan for Learning Resources required Assessment / Evidence

25

Appendix 4a: Example of a Local Action Plan

Midwife’s Name: A. Another Supervisor of Midwives: B. Anon

By the end of this Local Action the

midwife will have:

Action Plan for Learning Resources

required

Assessment / Evidence

Demonstrated that she meets the

NMC requirements for record keeping

Review NMC Guidelines on Record

Keeping

Review local Policy on Record Keeping

Review and reflect on own record

keeping, identifying areas for

improvement

Study Time

Access to NMC

standards/

guidelines

Consistently demonstrates the required standard

of record keeping

Supervisor of Midwives audit of standard of record

keeping

Demonstrated competence in the

identification of deviation from the

norm with appropriate escalation to

senior midwife/medical staff

Review of NMC Midwives rules &

standards

Review of NMC Code of Conduct

Review of case notes to assist in the

identification of deviation from the norm

Activities might include

Skills/ drills which include CTG

interpretation

OSCE type scenarios of differing levels of

deviation from the norm

Study Time

Access to NMC

standards/

guidelines

Access to case

notes

K 2 package

Consistently demonstrates identification of

deviation from the norm and informs senior staff

timeously

North of Scotland Local Supervising Authority Consortium

Cause for Concern Process · pathway care S Smith G Gold SWHMR Pregnancy Record Good continuity of...

Documents

Transcript of Cause for Concern Process · pathway care S Smith G Gold SWHMR Pregnancy Record Good continuity of...