DNV Healthcare Maternity Quality and Risk Forum

Transcription

1 DNV Healthcare Maternity Quality and Risk Forum Alison Bartholomew Director of Business Development, Baby Lifeline Training Ltd December London

2 Ensuring the healthiest outcome possible from pregnancy and birth by: Working with leading health & legal professionals to identify and prioritise equipment needs for the maternity sector Providing cutting edge, evidence based training for doctors, midwives and other healthcare professionals for continuing professional development

3 Background Driven by personal loss Established 1981 Award winning - Irish Medical Times Best Educational Programme in Ireland (2009) - The forum3 Alternative Rich List (2010) - Daily Mirror Pride of Britain Fundraiser of the Year (2011) - The Independent on Sunday Happy List (2011)

4 Fundraising > 9m raised to purchase vital maternity equipment Equipment ranges in cost from a few to many 000s per item Equipment helps with care for mothers and their unborn and new born babies Maternity care in both the community and hospitals as well as neonatal units

5 Training BIRTH series - an innovative educational series of 9 videos launched in 2000 in direct and practical response to CESDI report Training courses - > 10,000 healthcare professionals trained to date

6 Why BIRTH 2 UK? Some of this appalling catalogue of injury and associated misery [which results in maternity claims] can be reduced by improvements to training. Robert Francis QC (Baby Lifeline Fundraising Dinner, Nov 2013)

7 Why BIRTH 2 UK? True human and financial costs of maternity incidents Pain and suffering of the injured person Impact on family and friends Cost of future care provided by the state Distress caused to staff involved, many of whom will leave the NHS Cost of replacing staff, either on an interim or permanent basis Resources used on investigations, managing complaints, resolving claims and inquests Cost of clinical negligence claims NHS care that could otherwise be provided

8 Why BIRTH 2 UK? Findings and recommendations of various reports Reports of Confidential Enquiries into maternity care (Various) King s Fund Safer births: everybody s business (2008) NHS Litigation Authority Ten Years of Maternity Claims: An analysis of NHS LA data (2012) National Audit Office Maternity services in England (2013)

9 Key Findings of NHS LA Report - Summary 5,087 maternity claims with an incident date between 1 st April 2000 and 31 st March 2010 had been notified as at 1 st April 2010 Estimated total value of these claims was 3.1billion

10 Key Findings of NHS LA Report - Detailed studies CTG Interpretation The main allegations centred on the failure to recognise an abnormal CTG (46%) and/or act on it (40%)

11 Key Findings of NHS LA Report - Detailed studies Perineal Trauma Allegations centred on a failure to recognise the severity of injury and to adequately repair it

12 Key Findings of NHS LA Report - Detailed studies Uterine rupture Almost 50% of the claims reviewed involved a delay in diagnosis of rupture or impending rupture

13 Key Findings of NHS LA Report - Detailed studies Antenatal ultrasound investigations Most failures to detect anomalies were due to human error

14 Learning from NHS LA Report Need for more effective training and development of staff to ensure their competency Importance of closely monitoring the progress of labour and acting appropriately Vital that less experienced staff are well supervised continued

15 Learning from NHS LA Report Open and supportive culture, with staff aware of their own limitations and able to access assistance from senior colleagues is crucial to safety Effective multi-disciplinary team working, and mutual professional respect, is essential to the provision of safe care Maternity services must ensure that national guidance is considered and reflected appropriately within local guidelines and protocols - Guidance must be current, accessible, understood and acted on by staff and reviewed regularly

16 Other Reports and Statistics State of Maternity Services Report (RCM, Jan 2013) Predicted 743,000 babies will be born in 2014, an increase of almost a third between 2001 and % increase in births to women aged 40 and over between 2001 and 2011 Midwives are getting older, almost half are > aged 45 continued

17 Other Reports and Statistics Maternity Services in England (NAO, Nov 2013) 1 in 133 babies are stillborn or die within seven days of birth Outcomes in maternity care are good for the vast majority of women and babies but when things go wrong, the consequences can be very serious Cost of maternity clinical negligence cover in 2012/13 was 482 million

18 What is BIRTH 2 UK? Accredited courses Direct and practical response to NHS LA Ten Years report Key themes 6 distinct courses in 8 regions across the UK Evidenced-based Planned and delivered by leading experts Multi-disciplinary 3,500 part-funded delegate places Fees just 65 for NHS staff Promoting safety through best clinical practice and communication

19 BIRTH 2 UK Courses Labour Ward Dilemmas Best practice in intrapartum care The Fetus at Risk Antepartum assessment and management of the at risk fetus (preterm & growth-restricted) CTG Masterclass Intrapartum assessment of fetus and management of fetus at risk of intrapartum hypoxic injury The MaternityPEARLS Workshop Evidenced based management of second degree perineal tears Improving Safety & Outcomes in the Delivery Suite The role of Human Factors training Anatomy of Clinical Negligence Claims Medico-legal issues for the maternity team

20 BIRTH 2 UK Courses - Regions East Anglia London / South East Midlands North East Northern Ireland North West South West Wales

21 BIRTH 2 UK Courses - Information Directors Faculty One day Outline Programme Time-table CPD Booking information

22 Anatomy of clinical negligence claims Outline Clinical negligence claims in obstetrics and gynaecology account for half of the NHS litigation bill over the last decade. Moreover, the adverse clinical events which are the subject of these claims result in increased morbidity and mortality, and take a heavy psychological toll on both patients and staff. The NHS Litigation Authority report Ten Years of Maternity Claims has highlighted the lessons we may learn from these claims. Key themes to emerge from the report include the importance of providing effective supervision and support for staff in terms of training and development, the benefits of good multi-disciplinary working, and the need to ensure that national guidance is reflected within local guidelines and followed. This exciting and innovative one-day course will provide an overview of clinical negligence claims and the law that applies to them and how this relates to our everyday practice as busy professionals. The course includes sessions on the patient perspective, supporting staff involved in an adverse event and subsequent claim, an overview of how the legal system works from both sides, the role of the expert witness, documentation of care, coroner s inquests and their role to prevent future deaths, apologies and explanations when things go wrong, and how lessons can be learned to reduce the risk of future claims. Clinical and legal examples will be provided to illustrate learning points. The course is relevant to all members of the maternity team, including midwives, obstetricians and anaesthetists together with risk managers, claims managers and lawyers handling clinical negligence claims. Places on the course are limited to 72 attendees at each event. Part of the day will be spent in smaller groups to facilitate increased learning and delegate participation. Each session will be led by senior people with considerable experience in the relevant subject areas including clinicians involved in medico-legal work, lawyers, claims managers and risk managers.

23 Anatomy of clinical negligence claims Programme Aims To provide an understanding of clinical negligence claims Objectives To create an awareness of the experiences of both patients and staff affected by an adverse clinical event and subsequent claim To look at a coroner s inquest and its role to help prevent future deaths To describe the role of the expert witness and the importance of good documentation of care To outline the law as it applies to clinical negligence claims, including apologies and explanations To show how lessons can be learned to reduce the risk of future claims Content Patient experience Second victim concept Coroner s inquest Expert witness Legal perspective Apologies and explanations Learning lessons

24 Discussion & Questions