Maternity Services Governance & Risk Management Annual report Kathryn Halford, Director of Nursing

Transcription

1 ENC 9 Meeting Trust Board Date 30 July 201 Title of Paper Lead Director Author Maternity Services Governance & Risk Management Annual report Kathryn Halford, Director of Nursing Karen Palmer/Carol Hollington/ Sara Abrar PURPOSE OF THE PAPER To inform the Trust Board of the contents of the Maternity Services Governance & Risk Management Annual report SUMMARY OF THE KEY POINTS There have been 1931 incidents and near misses reported within the time frame 1st April st March of these graded severity Serious Incidents were reported relating to the maternity service during 2014/1 remaining the same as in the previous year. This included 1 never event. All were subjected to a Root Cause Analysis in line with local policy. Formal complaints reduced by 1, informal concerns reduced by, compliments increased by 14 but there was an increase in queries and referrals on to other departments. 29 new Clinical Claims were received by the Claims Department in relation to maternity services during this period. This was an increase of 11 from last year. The compliance for attendance at the Midwifery Mandatory Training sessions was 93% in 2014/1. Local process and practice changes implemented following investigations of complaints and incidents. Business case progression for Maternity and Neonatal service restructuring of estates and staffing. End of year- Red risks on the maternity risk register include: Non-compliance to national and local staffing levels within the maternity services due to activity levels and non- compliance to the nationally agreed standards for midwife to Supervisor of midwife ratios. (Currently under review by the NMC). Maternity Dashboard continues to monitor high risk areas and focus local auditing. Since June 2014 the maternity unit has commenced a work experience programme for students in school or colleges from the age of to gain valuable experience and insight at what a career in midwifery could entail. RECOMMENDATIONS To note and accept contents of the Maternity Services Governance & Risk Management Annual report and provide comment back to the Women s & Children s Services Divisional Quality team. 1

2 LINKS Strategic Objectives Good patient experience, safe delivery of care, good use of resources. Annual objectives Monitor / CQC / Regulatory Requirements IMPACT Patient Experience Satisfactory patient experience Quality & Safety Risks of Risk register Maternity estates and staffing Financial Business cases in progress Workforce Workforce annual audit completed. Business case in progress incorporates staffing requirements. Equality & Diversity Estates Consideration for the reconfiguration of maternity services being reviewed with Skanska and Estates department. IM&T Communications / Engagement Further development and implementation of the Maternity Information System being planned for 201. RISKS Activity and midwife to birth ratios above national averages. PREVIOUS CONSIDERATION Maternity Risk Group Women s & Children s Services Divisional Quality Team Quality & Safety Committee 2

3 Walsall Healthcare NHS Trust Maternity Services Governance & Risk Management Annual report Authors- K Palmer Head of Nursing and Midwifery C Hollington - Quality and Risk Management Matron June 201 3

4 Executive Summary This paper will summarise events which have occurred between 1st April 2014 to 31st March 201 within the maternity services, and will provide assurance to Walsall Health care NHS Trust Board that there is an embedded culture of risk management and governance. The maternity service has a well-defined Risk Management Structure which outlines staff s identified roles and responsibilities in relation to the management of risk. All these roles are defined within the Maternity Services Governance and Risk Management Framework document. There continues to be a robust risk reporting culture within the maternity services. All staff are encouraged to complete clinical incident reports as it is recognised that this practice promotes a safety culture. Clinical incidents and near miss events remain a standing agenda item at the following forums Delivery Suite forum Community Midwifery forum Neonatal Unit forum Antenatal/ Postnatal forum Maternity Risk Group Obstetric Speciality Quality Team Women s and Children s Quality Team. All new junior medical staff are given a brief at local induction about clinical incident reporting and risk management within the department. There have been 1931 incidents and near misses reported within the time frame 1st April st March of these graded severity 3-. Distribution of incidents by incident type included: 1074 Clinical Incidents 746 Maternity Managed Incidents 2 Non clinical incidents 39 Health and Safety Incidents ( accident or near miss accident) security incidents 1 violence and aggression incidents. 17 Serious Incidents were reported relating to the maternity service during 2014/1 remaining the same as in the previous year. All were subjected to a Root Cause Analysis in line with local policy. This included 1 never event. The ongoing monitoring and completion of action plans is undertaken by the Maternity Risk Group, and the Womens and Children s Divisional Quality Team, in addition serious incidents during this time frame have been monitored by the Trust s Serious Incident Committee. 4

5 The top five categories reported of Clinical incidents (total of 1178, excluding Health and Safety, Non clinical incidents and Maternity Managed Incidents) reported during 2014/1 were: Staffing (230) Investigations ( 126) Communication ( 9) Administration ( 7) Equipment (2) Incidents relating to health care records have been replaced by communication incidents in 2014/1 top. Complaints, PALS referrals and Clinical Claims There were 123 referrals to the Patient Advocate and Liaison service during April 2014 to March 201 in relation to Maternity services. This was an increase of 22. These include: 34 Compliments 27 Formal Complaints 1 Formal to Informal complaint 47 Informal concerns 7 queries 6 onward referrals 1 loss and compensation claim Formal complaints reduced by 1, informal concerns reduced by, compliments increased by 14 but there was an increase in queries and referrals on to other departments. 29 new Clinical Claims were received by the Claims Department in relation to maternity services during this period. This was an increase of 11 from last year.

6 INDEX Contents Page No. Executive Summary 4 1 Introduction 7 2 Maternity Specific Training 7 3 Clinical Negligence Scheme for Trusts (CNST) Maternity 8 Clinical Risk Management Standards/CQC Inspections. 4 Maternity services Governance and Risk meetings. 9 Maternity Services Risk Register 9 6 Woman s Services Policy and Guidelines Group 10 7 Maternity services Newsletter 10 8 Maternity Dashboard 10 9 Electronic Maternity Information System Midwifery Led service Snap shot Audit of Midwifery Staffing Obstetric Clinical Audit Perinatal Mortality and Morbidity meetings Statutory Supervision of Midwives 16 1 Clinical Incident reporting Complaints, Clinical Claims and PALS referrals Management of Highlighted Risk Areas Compliance to the Maternity Services Risk Management 27 Framework Annual Objectives 19 Appendices Appendix One- Maternity Risk Management Structure. 32 6

7 1.0 Introduction The purpose of this report is to inform the Women s, and Children s Quality Team and Walsall Healthcare NHS Trust Board of significant events and progress made to address key areas relating to risk management and governance within the maternity services. The report presents information from the financial year 1 st April 2014 to 31 st March 201. The report will also summarise compliance to the Maternity Services Governance and Risk Management Framework objectives, including those specific roles that have some level of responsibility for risk not only within the maternity services but also across the wider trust. 2.0 Maternity Specific Training Staff who hold key posts in the maternity services are required to undertake both risk management and root cause analysis training provided by the trust. Several existing staff are trained and using this skill within the service to undertake these investigations, and additional staff will be trained within the forthcoming year. In addition, maternity specific training for all groups of staff working within maternity services was monitored via the Continuing Professional Development Midwife. Escalation of quarterly reports in relation to training compliance was received by the Maternity Risk Group during this period. The annual report for maternity specific training for the last year will be presented at the July 201 Maternity Risk Group. Issues have been highlighted during the year in relation to poor access to elearning packages and IT issues. Some of these issues remain a concern and dialogue continues with the MLCC. In 2013/14 the Mandatory Midwifery Clinical Training Day was commenced for all midwifery staff to attend on an annual basis. Late into 2014 and through to 201 amendments have been made to the training programme in response to further legislation and changes to practice. The programme contains training on: Fire Safety, Manual Handling, Infection Control, Blood Transfusion/Products, Obstetric Risk Management update Since July 2014-Roles for HCA/MSW S in obstetric emergencies Since August Safeguarding Children Since October VTE assessment and Anti-Embolic Stocking use (theory only). As part of the maternity services learning from the investigation of incidents complaints/claims there have been changes made to training programmes to accommodate the recommendations. Examples include: Events and management which occurred in a Post-partum haemorrhage case was added to the mandatory skill drill training programme. 7

8 Perineal suturing was added to the midwifery mandatory training day following issues highlighted in relation to management of the perineum in labour and trauma sustained during birth. The compliance for attendance at the Midwifery Mandatory Training sessions was 93% in 2014/1. New Training Introduced for 2014/201 includes:- Grow/Gap Training for Foetal Growth Charts Diabetes in Pregnancy Anaesthetic Study Days on a 3 monthly basis High Dependency Study Day on a 3 monthly Basis Smoking Cessation as an E-learning Package Training Tracker-Medical Devices training Since June 2014 the maternity unit has commenced a work experience programme for students in school or colleges from the age of to gain valuable experience of what working in a maternity unit could offer. There is a national shortage of midwives and this opportunity is aimed at encouraging more students to undertake a career path in midwifery. 24 students have successfully completed the programme in 2014/201. A programme and certificate is given to each student with an appraisal sent to the school/college (see appendix 1). From June 2014 the Continuing Professional Development midwife has worked clinically with all newly qualified Band midwives, all new midwives to the Trust, and new midwives allocated to the delivery suite as part of their rotation. This is to support, guide and ensure that the midwives gain confidence and competence in working in a high risk obstetric unit as an autonomous practitioner. In addition, any midwives who are on performance management programmes are supported in a preceptor/coach role and the CPD midwife is a point of contact for this programme. 7 newly qualified midwives, 6 midwives new to the Trust and 2 midwives undergoing performance management have been part of this process. 3.0 Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical Risk Management Standards/ CQC inspections. The National Health Service Litigation Authority (NHSLA) previously developed and assessed all maternity units against a set of standards that had been in use since the 1980 s with regular review and updates. Walsall achieved accreditation at level 3 in February The new inspection regimes will be in line with CQC inspections. The Head of Nursing and Midwifery has attended external training relating to CQC inspections and the Quality and Risk management Matron has attended internal training which has been organised by the Director of Governance in preparation for the new style inspections. The maternity services are currently reviewing all reports from other maternity units that have received an inspection under the new CQC regulations. Preparations are on-going to form its own GAP analysis and action plans to address any deficits prior to the planned inspection in September 201. The preparation work is being project managed by the maternity governance team (information collation). 8

9 4.0 Maternity services Governance and Risk meetings. All maternity related risk management issues are discussed and escalated as outlined in the maternity services risk management flow chart (See Appendix One). Listed below is an example of meetings and escalation conduits: The Head of Midwifery has meetings with the Director of Nursing. Any maternity related issues are raised and added to the Director of Nursing report to Board or through Quality & Safety Committee. Feedback from the Maternity Risk Group is a standing agenda item at the monthly Women s and Children s Quality Team meeting. From this meeting maternity issues are escalated upwards to the Quality and Safety Committee and subsequently to Trust Board as and when required. The Head of Midwifery and the Associate Medical Director for the division attend this meeting. The monthly Maternity Risk Group meeting receives feedback from all the maternity local forums and ward meetings, escalating issues to the Women s and Children s Quality Team. The Head of Midwifery is a member of several committee s that are subgroups of Trust board i.e. Infection Control, Quality and Safety Committee, Safeguarding Committee and Trust Management board..0 Maternity Services Risk Registers Maternity services maintains a local risk register, this is a standing agenda item for discussion at the Maternity Risk Group and at the Women s Services Care group. High level risks (red and amber rated risks) are also reflected on the divisional Women s and Children s risk register. Local risks are discussed as a standing agenda item at departmental/ward local forums within maternity services. Escalation of risk upwards to the corporate risk register when required is via the Women s and Children s Quality Team meeting and then onward to the Quality and Safety Committee as appropriate. The risk registers continue to be updated by the owners of the risk and the risk register is available on the shared maternity P drive within the maternity service for all groups of staff to access. The live register is continually being updated in incorporating highlighted risks as and when they occur. The appropriate escalation route from these forums is upwards to the Maternity Risk Group and then to the Women s and Children s Quality Team. At the year end the maternity services had 2 red rated risks on the Divisional risk register which had been reported by Maternity services, these were: Noncompliance to national and local staffing levels within the maternity services due to activity levels. 9

10 Non- compliance to the nationally agreed standards for midwife to Supervisor of midwife ratio s. (currently under review by the NMC). 6.0 Women s Services Policy and Guidelines Group The Women s Services policy group played a vital role in the success services achieving the Level 3 CNST assessment level. Work continues with their bimonthly meetings. Work is ongoing to address guidelines that are currently in use as part of the rolling programme of review and update. An archiving system is in place, with a focus on improving the efficiency of retrieval of archived documents. The Comprehensive live log continues to be maintained and all guidelines and policies are available to all staff. In the clinical areas policies and guidelines are available on the maternity computer desktops by accessing the Maternity P drive or by accessing Walsall Healthcare NHS Trust Intranet site. A maternity representative is a regular member of the trust wide policy and guidelines group providing a valuable link with the maternity services. In 2014/1 33 guidelines and/or policies/standing operating procedures were revised or formulated and ratified by the service. Representation from all areas across the maternity services, midwifery and medical is encouraged. The Consultant lead for Obstetrics is a regular attender to the group meetings. 7.0 Maternity Services Newsletter The maternity services newsletter produced six editions in 2014/201. They are available on the maternity P drive for all staff. The newsletter provides updates to staff in relation to: Maternity delivery statistics Incident complaints and claims made with key learning actions Updates in relation to progress made towards external assessments New policies, policy revisions and guidelines information Clinical audit learning points Issues relating to Supervision of Midwives Fundraising, social information (staff births, success at education, marriages) and other notable events. Important points to note for that month. 8.0 Maternity Dashboard The maternity services dashboard continues to be a fluid working document. It is reviewed monthly at the Maternity Risk Group, using a red, amber and green rating system. It easily and visually highlights areas of compliance to local and national standards and guidance. It demonstrates monthly trends which can give an early indication of any adverse changes that may require further investigation. The dashboard captures five outcome measures relating to: Clinical activity 10

11 Workforce Clinical outcomes- Specifically high risk areas Complaints/Claims and PALS Achievement against locally set targets On-going audit for high risk areas within maternity services continues to inform the dashboard. These include Shoulder dystocia, perineal tears, Unit closures, Post-partum haemorrhage, and mode of delivery rates. The dashboard also provides advance warnings of adverse trends that initiate further in depth audits or investigation. In 2014/1 the dashboard prompted a more in-depth review of the high rates for induction of labour and births by caesarean section. The birth to midwife ratios have been reviewed in line with clinical outcome data and the acuity scores recorded on delivery suite against the monthly birth rate. The dashboard is forwarded to the local commissioners and is presented at Quality and Safety Committee. 9.0 Electronic Maternity Information System In April 2010 the neonatal unit commenced using Badgernet for the capture of local data. The system is used across the Staffordshire, Shropshire and Black Country Neonatal Network of which Walsall is a member. In 2012/13 the maternity service commenced joint working with Clevermed to develop a maternity equivalent system. This will address the maternity services vision to become paper light. There is a midwife lead who is involved with testing, training and communication of all changes that evolve with the system. Walsall GP s have the icon in their surgeries so that they can review any care their patients have received either in their surgery or at the hospital. We have an information sharing agreement with Sandwell and West Birmingham which is extremely beneficial for patient care, as many Sandwell women are choosing to birth in Walsall but receiving antenatal care in Sandwell. Sharing information reduces duplication and risk. Eventually the neonatal and maternity systems will be linked across the whole of the West Midlands. This will enable units that have transferred women/babies out to other units to keep track of their patient episodes of care and repatriate them back to their local area as soon as possible. There has been a significant delay in pursuing the full implementation of the IT system due to the cost of equipment. The delay to implement the intrapartum and postnatal packages is a clinical risk and has been added to the risk register. The slow progress is demoralising for staff as other units have full access and implementation, overtaking the Walsall service in technology that was developed in Walsall during the pilot project Midwifery Led service In April 2012 the midwifery Led unit opened in a location very close to Walsall town centre. The unit follows all risk management processes in line with the acute obstetric unit. All general incidents are investigated as per local and trust policy. All transfer incidents generated from the MLU are investigated via the Governance process in place for the review of incidents. This on-going 11

12 scrutiny and appropriateness of transfers and outcomes allows for the service to continual change and meet the expectations of users. It has resulted in practice changes to allow more women access to delivering in the unit and include: Changes to the suitability criteria Opt out option for delivery for low risk women Availability of pain relief ( pharmaceutical) Introduction of post dates non medical procedures to encourage the onset of natural labour. All midwives working in the midwifery led unit comply with all training requirements and work practices (including risk management and governance) adopted by all midwives employed by Walsall Healthcare NHS Trust. The total number of births for 2014/1 was 271 and work is in progress to increase the uptake. (See annual report for the MLU) Snapshot Audit of Midwifery Staffing. Excellent maternity care must be comprehensive and flexible to respond to the clinical and social needs of women and their families. For the majority of women, pregnancy and childbirth is a totally normal and uncomplicated experience but the service must be able to respond appropriately to those who may require highly specialised care for existing medical problems, social circumstances and any complications that may develop. The maternity services will need a workforce that meets all statutory and local guidance and takes account of the population and profile of the service to include: Volume of workload to be met ( to include acuity of patients) Quality of care to be achieved Effective and efficient use of resources Strategic direction of the service The birth to midwife ratio is monitored on the maternity dashboard information provided by the Head of Midwifery. During 2012 the SHA sponsored a birth rate plus table top exercise for all maternity units in the West Midlands. Birth rate plus uses the formula recommended in Safer Childbirth for safe staffing levels. The exercise indicated that Walsall should have a birth to midwife ratio of 1:31. During 2014/201 this ratio varied between 1:34 to 1:39. This was due to the overall increase in the rising birth rate for Walsall residents and the sustained increase of activity from the Sandwell area. The impact of the closure of Stafford s high risk obstetric unit in January 201 has not yet been fully evaluated. In addition to the guidance issued in Safer Childbirth it must be noted that the maternity services in Walsall use a variety of other supportive roles that are essential to service delivery. They are innovative roles that have not yet been recognised formally by national governing bodies. The workers are highly 12

13 trained and skilled in specific roles and are valuable team members. Their prime duties are theatre work, hostess/clerical and breast feeding support. In 2014/201 the maternity services used a significant amount of bank to support the service. The Director of Nursing has been given Trust Board approval to increase the establishment for midwives and the business case is currently awaiting approval. The maternity unit has a robust escalation policy and process for monitoring the acuity of patients in the most high risk area of maternity care ( delivery suite) in real time at 4hrly intervals throughout a 24/7 period. This enables the staff to respond to the demand and capacity issues in a timely manner and implement the escalation policy to keep women safe. Below are two examples of typical week s delivery suite acuity tool completed. 13

14 Snap shot activity score week commencing 09/02/201 7am 11 am 3pm 7pm 11 pm 3am OS AS US Date 09/04/1 09/04/1 09/04/1 09/04/1 09/04/1 10/04/1 Activit y No MW Date 10/04/1 10/04/1 10/04/1 10/04/1 10/04/1 11/04/1 Activit y No MW Date 11/04/1 11/04/1 11/04/1 11/04/1 11/04/1 12/04/1 Activit y No from MW ward Date 12/04/1 12/04/1 12/04/1 12/04/1 12/04/1 13/04/1 Activit y No MW Date 13/04/1 13/04/1 13/04/1 1304/1 13/04/1 14/04/1 Activit y No MW from ward from ward 9 1 from ward Date 14/04/1 14/04/1 14/04/1 14/04/1 14/04/1 1/04/1 Activit y No MW TL stayed from ward Date 1/04/1 1/04/1 1/04/1 1/04/1 1/04/1 16/04/1 Activit y No MW % % Totals Over staff 12/37. = 0.3 Under staff 92/37. =2.4 needed 64/37.= 1.7 MW NB acuity score matched with notation on team leaders shift report. 92 % 14

15 7am 11 am 3pm 7pm 11 pm 3am OS AS US Date 09/03/1 09/03/1 09/03/1 09/03/1 09/03/1 10/03/1 Activit y No 8 1 to 8 1 to MW ward ward Date 10/03/1 10/03/1 10/03/1 10/03/1 10/03/1 11/03/1 Activit y No MW Date 11/03/1 11/03/1 11/03/1 11/03/1 1103/1 12/03/1 Activit y No MW Date 12/03/1 12/03/1 12/03/1 12/03/1 1203/1 13/03/1 Activit y No MW Date 13/03/1 13/03/1 13/03/1 13/03/1 13/03/1 14/03/1 Activit y No MW from ward from ward Date 14/03/1 14/03/1 14/03/1 14/03/1 14/03/1 1/03/1 Activit y No MW Date 1/03/1 1/03/1 1/03/1 1/03/1 1/03/1 16/03/1 Activit y No MW to ward 9 1 to ward Totals Over staff 60/37. = 1.6 Under staff 24/37. =0.6 needed 84/37.= 2.2 MW % 84 0 % % 1

16 12.0 Obstetric Clinical Audit Clinical audit remains the tool of choice for achieving continual improvements. An active programme of clinical audit has taken place throughout the year with monthly meetings. All clinical commitments (except for emergency cover) are reduced or cancelled to allow medical staff to actively participate in the presentation of clinical audits. The audits are multidisciplinary with the nursing and midwifery team and other professions as necessary i.e paediatrics, ultrasonography etc. A total of 32 clinical audits were presented during 1 st April st March 201. Action plans were produced for the implementation of the audit recommendations when appropriate. Audits are monitored through the Women s service s care group agenda. Escalation of any concerns upward to the Women s & Children s Services divisional Quality Team. Items discussed at the clinical audit meeting in 2014/1 included: Patient experience ward score results Clinical Incidents Complaints/ Clinical claim information was disseminated as part of the amended agenda. Different pieces of local guidance/nice guidance and RCOG guidance were presented and discussed these included: Nice Quality Standard 73 Fertility problems, Long-term Consequences of Polycystic Ovary Syndrome Green top guideline No. 33 and Umbilical Cord Prolapse Green top guideline No. 0. Additional topics were presented and discussed which included: Duty of Candour and Never Events Perinatal Mortality and Morbidity meetings This is a multidisciplinary meeting for obstetricians, paediatricians, midwives, anaesthetists, general practitioners and other key stakeholders involved in maternity care. In 2014/201 there were 13 meetings. In 2014/ maternity related morbidity /mortality cases were discussed. The meetings are well attended and provide: Maternity statistical data Discussion of interesting medical/midwifery case studies Critical analysis/discussion of care with poor pregnancy/maternal outcome A valuable forum for the discussion and agreement for future pregnancy planning in individual cases A forum for the dissemination of lessons learnt from the discussion of cases with poor outcomes Statutory Supervision of Midwives Walsall maternity services have an active team of Supervisors of Midwives. Throughout 2014/201 they have been involved in all aspects of governance. 16

17 They attend root cause analysis meetings and other various forums relating to risk management. As a group, they provide a 24/7 on-call arrangement for supervision through a monthly rota which is accessible to all midwives. They are involved in the units staffing escalation policy, and forward plan to recruit midwives into Supervision. In line with their duties they support midwives under investigation for practice issues and they develop individual improvement/reflective action plans for midwives as required. They provide reports for the Head of Midwifery on all midwives that have undertaken Supervised Practice. The team received their last annual inspection March The inspection did not highlight any concerns with Supervision or the role of the Supervisors of Midwives at Walsall. The action plan against the standards was presented at the Maternity Risk Group meeting and the Women s and Children s services Quality Team for governance and monitoring purposes. The process of review of maternity services supervision for 201 has been revised by the LSA. The Walsall team are to expect their next review in early The current Supervisor to Midwife is below national standards but work is ongoing to recruit Supervisors, as others approach retirement. In 2014/1 1 Supervisor retired and 2 more qualified. During 2014 the NMC reviewed the function of Supervision in response to issues raised at Morcambe bay and recommendations made in the Kirkup Report. There will be changes made over the next two years as the NMC resumes overall regulatory responsibility for midwives in line with nurses. The action plan for 2014/1 has been completed. 1.0 Clinical Incident reporting. In 2014/ Incidents/near miss reports were completed by teams working within, or by staff who are in contact with the maternity services. This is an increase of 400 incidents on the previous year. During the reporting period the incidents were recorded using the trust wide electronic incident reporting system Safeguard. This level of reporting demonstrates a healthy reporting culture within departments across the maternity services. Incidents are discussed as standing agenda items at monthly team meetings: Maternity Risk Group Obstetric clinical audit meeting, Delivery suite forum Neonatal unit forum Community midwifery forum Antenatal/ post-natal forum Women s and Children s Quality Team 17

18 Monthly reports detailing all locally reported incidents, complaints and claims received to the speciality are presented at the local forums within maternity services. In addition Quarterly trend based reports were formulated and presented to the Womens and Children s Quality team. These reports are available for staff access via the shared P drive. There have been 1931 incidents and near misses reported within the time frame 1st April st March of these incidents were graded in 3- severity categories. Distribution of incidents by incident type included: 1074 Clinical Incidents 746 Maternity Managed Incidents 2 Non clinical incidents 39 Health and Safety Incidents ( accident or near miss accident) security incidents 1 violence and aggression incidents. The top five categories reported of Clinical incidents (total of 1178, excluding Health and Safety, Non clinical incidents and Maternity Managed Incidents) reported during 2014/1 were: Staffing (230) Investigations ( 126) Communication ( 9) Administration ( 7) Equipment (2) Incidents relating to health care records have been replaced by communication incidents in 2014/1 top. Please note: maternity services report incidents within the category Maternity Managed Category relating to pregnancy and birth as part of a regional data set. These include a significant number of incidents which do not necessarily have an adverse outcome or are near miss events. They are reported to track trends in clinical practice and clinical outcome measures through medical notes review and audit against policy. The incidents are entered onto the Safeguard data collection system and are reported in trend reports within as Maternity Managed Incidents (MMI) or events. 1.3 Serious Incident Reporting 17 Serious Incidents were reported by the maternity service during 2014/1. All were subjected to a Root Cause Analysis in line with local policy. This included 1 never event. The on-going monitoring and completion of action plans is undertaken by the Maternity Risk Group, and the Womens and Children s Divisional Quality 18

19 Team, in addition serious incidents have during this time frame been monitored by the Trust Serious Incident Committee. Incidents reported were in line with NHS Walsall and Trust guidance for serious incident reporting. They included: Intrauterine deaths> 37 weeks gestation. Unexpected Neonatal death. Maternal transfer to Acute Intensive care Unit Baby born with Apgar of< 4 at minutes of age. Intrapartum death. Never event: Retained abdominal swab at caesarean section. Extensive action plan and local surveillance and monitoring has been implemented in response to this event. 1.4 Examples of changes in practice within Maternity services as a result of incident reporting and investigation. Training sessions arranged for staff to gain updates in Newborn blood spot screening. Managers performing some of the Local RCAs within the Division as more staff attend training. Revision of Foetal remains disposal pathways to provide clear guidance for staff in the correct process for the disposal of foetal remains within the trust. Local guidelines amended in response to local review of case management. Emergency Anaesthetic Drugs process reviewed and changed in Maternity theatre. Introduction of monthly continuous audit of antenatal tests review by the community midwife. Awareness raising of staff in relation to missing copies of the resuscitation sheet and any additional documentation in relation to Neonatal resuscitation. Formalised process for time out to count when the swab, instrument and needles checks are being carried out in maternity theatre will enable the staff checking to focus on the checking process. Focus for staff on good coordination and cohesiveness of the team when using blood and blood products in cases of massive Obstetric Haemorrhage cases. Review of the process for managing vaginal bleeding following a rise in complaints/claims in this field. Any vaginal bleeding with a history of ragged membranes or incomplete 3rd stage of labour must alert the team and staff to have a low threshold when considering taking women to theatre for examination under anaesthetic. Cascaded to staff in Maternity services the requirement that surgeons must clearly communicate to the scrub and circulating staff in the rare circumstance that requires a radiopaque swab to be placed in the abdomen, that a swab is in situ, this must be clipped to the operation drape and the fact that a swab is retained in the abdominal cavity is clearly documented on the operating theatre white board. 19

20 Staff informed that only accurate and factual, not subjective records to be maintained at all times. Staff have completed personal reflective practice following some of the reviews- these being discussed with either educational supervisors or Supervisor of Midwives. A standard operating procedure (SOP) prior to the training and implementation of the tidal ET monitoring for difficult neonatal intubation has been devised An SOP for staff guidance in arranging interpreter services has been devised. Guidance issued to staff ensuring that women who are risk assessed as requiring an interpreter for antenatal assessments must arrange for an interpreter to be present for all planned contacts. The importance of completing the patient record sheet by the ambulance crew in full will ensure all pre admission data is available at the time of the assessment of patients. All the times are recorded on their radios and computer system that is linked to ambulance control this assist with timeline establishment when reviewing incidents. That the 2222 call when an emergency case is en-route into the hospital via an ambulance would be helpful and ensure teams are prepared for the incoming emergency. Staff to ensure signatures and printed names are completed when writing in all records. This includes those staff scribing at the time of the emergency. The checking of essential equipment as per local guidance is required to ensure it is ready for use at all times in an emergency situation. Clinicians must at hand over of care to another obstetrician state any concerns they have in relation to a patient and appropriate communication to the Consultant must occur. Midwives to ensure that student midwives receive the appropriate mentoring at all times. A process must be in place to ensure the ultrasound machine in use on delivery suite is fit for purpose and maintained. Team leads on the delivery suite should have a low threshold in ensuring the opening a second theatre is initiated when a category 1 caesarean section is required and the maternity theatre is occupied. That all loose filing must be filed in the hospital records. This is everyone s responsibility Patient Experience 2013/ Complaints There were 101 referral to the Patient Advocate and Liaison service during April 2014 to March 201 in relation to Maternity services. 20

21 These included: 20 Compliments 28 Formal Complaints Formal to Informal complaint 2 Informal concerns 28 Complaints were received by the maternity service during April 2014 to March 201. The complaints received related to communication and care delivery issues. Communication was perceived to be poor between users and the medical/midwifery teams and between medical teams. The management of post-partum haemorrhage was seen as a trend being reported in 4 of the complaints received. Changes in practice/action taken as a result of complaints include: Changes in Maternity theatre practices following environmental and infection control reviews. Training in the management of Post-partum haemorrhage based on a case review, of the management of Obstetric Haemorrhage particularly in relation to communication between team members. Review of scanning appointments and additional scanning clinics have been provided to address service demand. Staff involved in cases where attitude issues have been raised are referred to their Supervisor of Midwives for reflective practice (sharing the complaint). Delivery suite midwives visit women they have delivered on the post-natal ward the following day to try and address any of the communication issues relating to their birth prior to leaving hospital. A policy change has resulted in women staying in hospital for a minimum of 4 hours following the diagnosis of early labour Some decoration and environmental works have been done on the postnatal wards/delivery suite and the MLU 3 formal disciplinaries have taken place with staff, following the Trust process for investigation. The distribution of the 20 Compliments received by the Maternity services are displayed in the table below: 21

22 Inpateint wards Ward 27 Ward 28 ANC MLU Maty Theatre Some of the compliments received from the women: To all staff on NNU, Thank you for your kindness, love and support which you have shown to our baby. Many thanks for your recently letter regarding the issues I had with a recent visit with my daughter to the antenatal clinic, I am satisfied that the issues raised have been dealt with satisfactorily and hopefully it will bring about some changes in the department. You do an excellent job, thank you ever so much for looking after me, really appreciate it. Thank you for taking time to listen to my concerns and experience. I felt like I was taken seriously and was listened to by the Matron and Midwife. Thanks again I did not expect a response from and am very grateful I had the chance to talk through everything. Wanted to take this opportunity to let you know about the fantastic care received during my recent pregnancy and birth. The care was second to none, professional, helpful, friendly and caring. The care was above and beyond our expectations and would recommend your hospital to any pregnant friends Clinical Claims 18 new Clinical Claims were received by the Claims Department in relation to maternity services during this period. The table below shows the claimants allegations and current status. 11 Obstetric Clinical Claims were closed during the period 1st April 2014 to 31 st March 201. Month received Allegation Status April 2012 Management of labour and subsequent Hysterectomy in Local root cause analysis did not identify any omissions or issues with care given. On-going investigation May 2012 Allegations not specified- On-going investigation in place July 2012 gave birth in trust 2011 Management of labour and subsequent Hysterectomy Local root cause analysis highlighted areas for improvement- learning disseminated included: Good practice 22

23 measure to involve senior medical staff involvement early in complicated operative deliveries. Timely recognition of the early signs of internal bleeding essential to good outcomes. Case to be used as Clinical Scenario for local multidisciplinary training. Ongoing investigation August 2012 Care in labour On-going investigation in place September 2012 Neonatal death and Local root cause analysis highlighted Management of Maternal areas for improvement-a short delay in Diabetic Ketoacidosis recognising Clinical urgency and managing the Diabetic Ketoacidosis in this patient. There was a failure for medical staff to recognise a pathological foetal heart rate trace and suboptimal glycaemic control antenatally Learning points disseminated included: Review of the Diabetes in Pregnancy Trust policy in relation to antenatal pathway Feedback was provided to medical Locum Agency and future attendance of this Doctor blocked and Review competency process of locum medical staff. If locum on duty this should be a low threshold to contact and request Consultant to attend. Individual Feedback to medical staff in regard to interpretation of electronic foetal monitoring traces in this case was performed. Reinforce guideline to medical staff and midwives in regard to antenatal visits in pre-existing diabetic patients. Pathway displayed in the Antenatal clinic rooms. On-going investigation September 2012 Care in labour and birth On-going investigation in place October 2012 Alleged failure to arrange transport home. Walked 6 miles home. Delivered baby at home November 2012 November 2012 Waiting for Clinician comments Ongoing investigation Birth Injury Cerebral palsy On-going investigation baby Caesarean section. Post-natal Waiting for Clinician comments On- 23

24 readmission and further going investigation surgery November rd degree tear repair On-going investigation December 2012 Neonatal transfer from On-going investigation neighbouring Neonatal Unit and care received on Neonatal Unit Walsall December 2012 Management of retained Waiting for Clinician comments Ongoing products of conception investigation January 2013 Birth Injury- Child has Ongoing investigation Epilepsy January 2013 Management of retained A Local root cause analysis products of conception highlighted areas for improvement- When Consultants present in theatre with Trainees- good practice to Scrub with the trainee, give support and also reduce any delays if senior assistance required. Alternative management could have been undertaken to deliver in this case. The group discussed whether a trial was appropriate in view of labour history. However this would have not necessarily made a difference to the outcome, staff to ensure that a full overview of woman s history and all events is undertaken prior to making any decisions about mode of delivery. On-going investigation January 2013 Management of Delivery and On-going investigation birth January 2013 Failure to diagnose dislocated On-going investigation hip at birth February 2013 Management of Retained products of conception March 2013 Infection following Caesarean birth A Local root cause analysis highlighted areas for improvement - The importance of complete and accurate medical documentation highlighted to staff on obstetric study day. To ensure that all readmissions or cases for concern are written in the Doctor s book for medical reviews and receive inpatient senior review Review of frequency of maternal observations required to ensure appropriate level of monitoring is being undertaken whilst inpatient. A Local root cause analysis highlighted areas for improvement - The Obstetric Consultant must be 24

25 informed of any women whom are readmitted /unwell, and a Senior review must take place on a daily basis. An electronic discharge summary must be completed for all women whom have been readmitted/returned to theatre or whom require medical discharge from hospital. Obstetric medical staff and Midwives working on the maternity inpatient wards must perform a review of the maternal observation frequency when performing a management review. Any frequency of observation/exception report in relation to observations is to be amended and documented on the Maternity Early Warning Chart. Communication of patients whose condition deteriorates whilst awaiting Specialist team review must still be reviewed by A&E medical staff whilst in the department Patient Experience and Engagement In 2014/1 patient experience was captured through the friends and family test. All women that delivered a baby during February 201 will be surveyed as part of a 3 yearly national rolling programme focussing on maternity care. During 2014/201 there were some very positive comments received across the maternity service from the IWGC scores. Some examples are listed below. Matrons are encouraged to display these in staff areas for information sharing and share personalised comments with staff members. Maternity: Extremely helpful and caring staff, lovely environment for a stress free birth. "Wonderful caring and friendly staff. Made a major operation into a pleasant stay. Thank you." Very friendly staff. Caring and kind. Helpful at all times. Everything was fantastic. Thank you all for the help and support. The staff were friendly and gave me the care I needed. "Midwives were excellent and provided excellent care. Throughout delivery and after. Clean ward throughout. 2

26 "It was great, friendly staff! Very comfortable stay!" Quick and friendly response, midwifes caring and polite. "Everyone is sweet, caring and wants to help! felt so welcome and looked after. Thank you! "Everyone is very nice and really look after you. Job well done. Thank you." Antenatal clinic is very good to know about your health in pregnancy. "Staff are friendly and helpful. I am always made to feel welcome." All of my care, they looked after me really well. Lovely staff and good service. Friendly staff. The staff are really good and they let u know what s going on. "The Sonographers were very friendly and professional. My midwife always answered my questions and provided excellent service. Midwives could be available for more than 1 day per week at the GPs surgery. Every member of staff looked after me so well and my baby- couldn't have asked for better care. In 2014/201 there has been a rising trend in informal concerns relating to long waits in the antenatal clinic and other capacity issues around delayed treatments. There is a longer term estates strategy that will eventually address the capacity issues Management of Highlighted risk areas A number of measures have been put in place to address the risks identified both throughout the audit period and as a result of the collation of this report. These include: Changes to the Maternity dashboard to reflect progress and movement of measures against local and national targets. Midwifery workforce review by the Head of Midwifery in addressing the increase in activity seen across the maternity service and working towards national and local staffing compliance rates. Consultant Obstetrician review of the Consultants workforce in addressing the increase in activity and the subsequent compliance to national targets for Consultant presence on the Delivery suite. Continuation of on-going audits and local feedback of the high risk clinical incidents that occur- i.e Emergency Caesarean section, Induction of labour, Shoulder Dystocia, Postpartum Haemorrhage. Maternity information system board and group in place to take forward the expansion of the IT system into Phase two. Business case to be presented to Trust board for the expansion of the current Maternity and Neonatal services to accommodate the increasing pressures on the acute maternity service Task and Finish groups set up to examine high risk incidents, i.e Postpartum Hysterectomy, Diabetes in pregnancy management, Sepsis management. 26

27 Stress testing programme formalised within the division to assure the teams that processes implemented are still in place and functioning Maternity services Risk Management Framework Objectives. The maternity services have a risk management framework that details how the service manages its risk and oversees governance, linking to the acute trust. See Appendix One. The Maternity Services Risk Management Frameworks list of objectives includes: To describes the process for the management of the maternity service s risk register. Provides a description of the maternity service s risk management structure, detailing all the committees/sub-committees/groups including those within the acute trust which have some responsibility for risk within the maternity service Provides a description of the trust wide and maternity service leadership arrangements of all individuals whom have the responsibility for trust wide risk and Maternity specific risk related issues. Describes the process by which the Trust board executive lead with responsibility for risk related issues within the maternity service communicates with and obtains assurance from the maternity service. Provides a description of the duties of the named individuals with responsibility for risk within the maternity service. Describes the process by which the maternity service receives and reviews the Local Supervising Midwifery Officers annual report and the formulation of the maternity services action plan in response to the report. Describes the process for the immediate escalation of risk management issues from the maternity service up to Trust Board level. Describes the processes involved for monitoring compliance with all of the above requirements, the subsequent review of results and subsequent monitoring of action plans formulated. Monitoring of the framework objectives: An extensive monitoring process is described within the Framework document describing how the service audits its compliance to the frameworks objectives, examples of the compliance for 2014/1 is detailed below. Denotes Noncompliance to objective Denotes complaint to objective 27