Agenda item

Members of the Committee considered a verbal presentation from Dr Anton Sinniah, Pennine Acute NHS Trust, in relation to the recently conducted external review of maternity services within the Trust.  The presentation contained the following information:

Following the appointment of the new Chief Executive a system was introduced whereby all serious untoward incidents were notified to the Chief Executive and Executive Directors within 24hours and discussed at senior management team on a weekly basis.

The report highlighted several incidents within maternity services.  The incidents were reviewed through the Trusts own root cause analysis.  The Trust commissioned an external review of nine incidents which had occurred in maternity services six neonatal and 3 maternal deaths.

In summary, the findings of the external review were:

·         The population of women cared for at Pennine Acute Trust is diverse and challenging and includes a significant number of high risk and vulnerable women.

·         There are clearly areas of good practice which are appropriately noted and acknowledged and which should be widely shared.

·         The three maternal deaths did not appear to be the result of deficiencies in care.

·         The serious incidents were thoroughly and comprehensively reviewed by the Trust and there was a clear, honest and open approach to identifying failings.

There were twelve recommendations made as a result of the review and a comprehensive improvement plan has been drawn up to address the issues raised.

Dr Sinniah expressed concern that a member of Trust staff had spoke to the Manchester Evening News in advance of publication of the report.  The Trust spoke to the families concerned in advance of publication, however acknowledge that liaison with the family members could have been better.

Those present were given the opportunity to ask questions and make comments and the following points were raised:

Dr Sinniah reported that there have been a number of changes to senior management at the Trust since the commencement of the external review; the appointment of a new Chief Nurse as well as a new Deputy Chief Nurse, the appointment of a new Director of Governance and an Acting Medical Director.

In response to a Member’s question Dr Sinniah acknowledged that when the external review commenced, the Trust should have informed those families directly affected.

Dr Sinniah reported that the outcome of the external review confirmed that the outcomes for those concerned were not preventable but the Trust could have done things differently.

Dr Sinniah confirmed that any death that occurs up to 365 days after giving birth is recorded as a Maternal death.

Following the decision to conduct an external review, the Trust informed the local CCGs as well as the Trust Development Authority.  An incident management group has been established which is co-chaired by Gill Harris, Pennine Acute’s Chief Nurse and Stuart North, Bury’s CCG Chief Operating Officer.

In response to a Member’s question, Dr Sinniah reported that there has been some ongoing media interest in the Trust’s maternity services.  The Trust’s Chief Nurse has meet with a journalist from the Manchester Evening News and explained the background to the review and a further more balanced piece was printed.

In response to a Member’s question, Dr Sinniah reported that in response to the concerns raised about clinical leadership the Trust must ensure that there is clarity in relation to individuals’ roles and responsibilities and that information is disseminated.

Dr Sinniah reported that the Trust provides a high level of consultant cover.

In response to concerns raised by Members, Dr Sinniah reported that in individual cases, a failure of staff to escalate concerns did lead to poor outcomes.  The Trust has subsequently twinned with Newcastle Hospital NHS Foundation Trust to share best practice.

In response to a Member’s question, Dr Sinniah reported that the external review did not highlight concerns in relation to a shortage of midwives but rather a shortage of health care assistants.

Stuart North, Chief Operating Officer Bury CCG reported that the CCG have been involved in overseeing the process and there will be issues for the CCG as well as the Trust to take forward.