Report Summary Sheet · Maternity: Morecambe Bay Actions Page 4 of 25 26th May 2016 Morecambe Bay...

Maternity: Morecambe Bay Actions of 25 26

th May 2016

Report Summary Sheet

DETAILS Part 1

(Open)

X Part 2

(Closed)

Agenda Item 4.1

Meeting Board

Date 26th May 2016

Title of Paper Maternity update following Morecambe Bay review

Executive Lead /

Clinical Lead

Dr Liz Hersch

Author Catherine Phillips

Appendices A. Self-assessment

B. Improvement Plan

C. Structure chart

Request Approval Discussion Information Assurance X

EXECUTIVE SUMMARY

Purpose The purpose of this report is to provide assurance to the Board on

the RUH actions following the completion of a self-assessment in

relation to the findings from the Morecambe Bay review undertaken

by Dr Bill Kirkup in 2015 as well as provide assurance of the process

to monitor the improvement plan in relation to the Morecambe Bay

review.

Recommendation The Board is asked to:

Review and note the self-assessment against the Morecambe Bay Review recommendations and associated improvement plan.

Consider whether further updates on the RUH improvement plan in relation to the Morecambe Bay review are required, or whether you are happy for commissioners to continue to monitor on your behalf through the contractual process.

The Board is also recommended to receive and review the RUH self-assessment in relation to the subsequent National Maternity Review, together with commissioner self-assessment of the recommendations. This is expected in June 2016.

Risk High Medium X Low

Impact on Quality The Morecambe Bay report investigated serious incidents and

failings in maternity care at Furness General Hospital. The report

therefore provides learning for all maternity providers to make


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services safer and more transparent.

Commissioners asked the RUH to assess themselves to identify

what makes them different from FGH and whether there were

opportunities to make improvements in the quality of service

provided to families in BaNES and Wiltshire. Actions have been

identified to improve quality and reduce risks, although overall, the

self-assessment highlights some good practice at the RUH.

Impact on Finance

No impact to commissioners in relation to this review.


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Maternity update following Morecambe Bay review

1. Executive Summary

1.1 The review into maternity services at Furness General Hospital concluded that there were serious failings in the service provided to women and babies which resulted in death and serious harm and which were not addressed at many levels. The report made recommendations both to FGH and to wider maternity services. This paper briefly summarises the findings of the Morecambe Bay report, identifies the importance of Boards oversight of maternity services and then summarises the self-assessment and associated improvement plan carried out by the RUH. Both are attached in full in the appendices.

1.2 In early 2016, the National Maternity Review1 was also published with further

recommendations on the vision for maternity services.

2. Recommendations

2.1 The Board is asked to review and note the self-assessment against the Morecambe Bay Review recommendations and associated improvement plan.

2.2 The Board is asked to consider whether further updates on the RUH

improvement plan in relation to the Morecambe Bay review are required, or whether you are happy for commissioners to continue to monitor on your behalf through the contractual process.

2.3 The Board is recommended to receive and review the RUH self-assessment in

relation to the subsequent National Maternity Review, together with commissioner self-assessment of the recommendations. This is expected in June 2016.

3. Background

3.1 In 2015, Dr Bill Kirkup, commissioned by the Department of Health, published his independent review2 into failings in maternity care at Furness General Hospital (FGH) in the period January 2004 to June 2013. The investigating team included a panel of expert advisors in obstetrics, midwifery, paediatrics, nursing, ethics and clinical governance.

3.2 The report concluded that the maternity unit at FGH was “dysfunctional” and

that “serious failures of clinical care” led to “avoidable harm to mothers and babies, including tragic and unnecessary deaths” (P5, The Report of the

1 https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf

2 The Report of the Morecambe Bay Investigation, 2015,

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf




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Morecambe Bay Investigation, 2015). Poor clinical care led to the preventable deaths of one mother and eleven babies.

3.3 The report describes five key areas in which there were problems affecting

care, described as a “lethal mix” (P14): 1. Clinical competence of staff fell below expected standards for a safe and

effective service. Substandard clinical practice was found amongst midwives, obstetricians and paediatricians.

2. Working relationships between groups of staff were “extremely poor”. There was a lack of multidisciplinary working and poor communications between teams. Clinical records were poor and often written in retrospect, further hampering clinical handover between teams.

3. Midwifery care in the unit was strongly influenced by a few dominant

individuals who pursued natural childbirth in an over-zealous manner which led to inappropriate and unsafe care at times. This occurred without real challenge from other professions or to the exclusion of other professions, e.g. midwives risk assessing women without the input of obstetricians.

4. Advice to mothers that it was appropriate to deliver at FGH was

“significantly compromised by a failure to assess the risks properly”. This included the risk that the neonatal paediatric service was not equipped to provide intensive care to very pre-term babies, resulting in the transfer of very sick babies who should never have been delivered at FGH.

5. The response to clinicians in the unit to serious incidents is described by

the report as “grossly deficient”. Incidents were investigated by a single midwife, rather than a multidisciplinary team, who produced very brief reports which failed to identify key areas of failure in care and which were “inappropriately protective” of midwives and lacked any visible approach to sharing lessons learned.

3.4 The report goes on to describe serious incidents and missed opportunities to

identify and rectify the practice at FGH. These opportunities were missed at every level, both clinical and managerial, including within the organisation itself and their commissioning organisations. Opportunities were further missed as structural changes in the NHS meant that complaints were not properly handed over and followed up, alongside confusion in responsibilities both at an individual and organisational level. Aligned with this was the objective of FGH to gain Foundation Trust status which may have contributed to lack of oversight, for example, at Board level.

3.5 The report concludes with a series of 18 recommendations for FGH and a

further 25 actions for the wider NHS. One of these actions (25) is for NHS Boards to have a duty to “report openly the findings of any external investigation into clinical services, governance, or other aspects of the operation of the Trust”. Whilst the attached does not constitute an external review of the service,


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it does contain a transparent reflection of the service provided by the RUH, overseen by commissioners, and therefore it is deemed appropriate that the CCG Board should have oversight of the findings and action plan, given the findings from the FGH Review.

4. Local Maternity Services

4.1 The RUH is responsible for delivering maternity services to women and families, predominantly in the area covering BaNES and Wiltshire, but some women from Somerset and South Gloucestershire may choose to deliver at the RUH. As part of the acute contract with the RUH, the service is commissioned to provide maternity services to facilitate delivery at home, in the Free Standing Midwifery unit (Paulton) or in the acute hospital (with midwives and obstetricians if required). They provide antenatal, intra-partum and postnatal care.

4.2 Maternity care is different to many other NHS services in that it provides a

window on the NHS for well people: pregnancy is a normal physiological process in many women’s lives. The Morecambe Bay review describes a safe maternity service as “maintaining vigilance for early warning of any departure from normality and on taking the right, timely action when it is detected”. Although adverse events are relatively scarce in maternity care, it is therefore important that every event is investigated to identify whether standards have been met and if learning can be shared to prevent further such incidents.

4.3 When the Morecambe Bay review was published, commissioners requested

that the RUH self-assess against the recommendations. This took a little time to return to commissioners as the RUH understandably wanted to give their Board oversight of the process. The report was finally submitted to commissioners in December 2015 at a point of further change in the organisation as the Head of Midwifery was leaving.

4.4 Commissioners responded to the RUH self-assessment in December, with a

number of questions and observations:

How the self-assessment was completed, e.g. Head of Midwifery completion or Multidisciplinary team?

Noted rather optimistic assessment of known areas for improvement (specifically, recruitment and retention of staff, changes in senior staffing, availability of consultant input, training and appraisal levels)

Noted lack of evidence provided around specific areas, e.g. staff rotation, working relationships and providing informed choice to women.

Request for an updated action plan in response to a more detailed self-assessment.

4.5 In March 2016, commissioners received a revised version of the self-

assessment and improvement plan (See Appendix A and B). The response clarified that the self-assessment and improvement plan had been completed in multi-disciplinary team meetings. Updates, including rating (red, amber, green)


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were more reflective of the risks identified and changes required (some already in progress).

4.6 The full self-assessment is attached in Appendix A, but in summary, the RUH

identified that they could make improvements in relation to:

A review of skills, knowledge, competencies and professional duties of care.

Training and development of staff including opportunities to broaden staff experience in other units.

Requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation.

Developing better joint working between main hospital sites, including the development and operation of common policies, systems and standards.

Linking with a partner Trust, so that both can benefit from opportunities for learning.

Review of arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support.

Notably, there are no “Red” rated recommendations and the RUH has provided good evidence of multidisciplinary team working.

4.7 The full improvement plan is attached in Appendix B, but in summary, the

agreed key actions are:

Training Needs Analysis to have greater multi-disciplinary involvement and oversight in the Division.

Commencement of Band 7 midwife rotation (from February 2016).

Further analysis of South West dashboard (benchmarking) to understand outlying data.

Development of a Clinical Incident Review Group for the Women and Children’s division.

Restructuring of midwifery management structure (see Appendix C for new management structure).

Re-advertisement of the Head of Midwifery role. 4.8 A formal update to these actions is expected by Commissioners in June.

Informally, there appears to be good progress on actions so far. The main difficulty is in recruiting to the vacant Head of Midwifery role (since end December). Interim arrangements are in place, shared between the Children’s Matron, Divisional Manager and Senior Midwife. The management structure is stronger and clearer now with Community and Acute Matron roles but the Head of Midwifery role does need to be filled.

5. Resource Implications 5.1 None to commissioners.


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6. Consultation 6.1 No patient consultation has taken place in relation to presentation of this review

and associated action plan. The RUH will continue to consider further means of

engaging maternity patients to provide feedback, in line with recommendations

published more recently in The National Maternity Review3.

7. Risk Management 7.1 Risks are identified and action plan provided in the attached improvement plan.

8. Next Steps 8.1 Commissioners will continue to monitor delivery of the RUH improvement plan in

relation to the Morecambe Bay review and subsequent self-assessment. This will

be achieved through existing quarterly Performance and Quality meetings for

RUH maternity services.

8.2 The RUH Board will also continue to receive updates on the improvement plan.

BaNES CCG Board is asked to consider whether further updates on the

improvement plan in relation to the Morecambe Bay review are required.

8.3 In early 2016, the National Maternity Review4 was published with further

recommendations on the vision for maternity services. The RUH has again been

asked to review these recommendations and present to commissioners in June

2016. BaNES CCG Board is recommended to receive and review the RUH

self-assessment in relation to the National Maternity Review, together with

commissioner self-assessment of the recommendations.

Equality &

Diversity

Applicable Not Applicable X

An Equality Impact Assessment is not applicable at this time as direct service

changes have not been made. Recommended changes relate to service

governance, training and staff working.

Public &

Patient

Engagement

Applicable Not Applicable X

Not applicable at this time as direct service changes have not been made.

3 The National Maternity Review (2016) https://www.england.nhs.uk/wp-

content/uploads/2016/02/national-maternity-review-report.pdf 4 https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf





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Appendix A: RUH self-assessment and improvement plan The RUH completed a self-assessment against the recommendations of the

Morecambe Bay Review and have created an improvement plan associated with this,

detailed in Appendix B.

Appendix A: RUH self-assessment against the Morecambe Bay Recommendations


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Appendix B: RUH Improvement Plan in relation to the Morecambe Bay Recommendations


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Appendix C: RUH Maternity structure chart


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Appendix C: Maternity structure chart

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