Agenda item

Gill Harris, Chief Nurse and representatives from the divisional team for Maternity Services will be in attendance.  Report attached.

Representatives from the Pennine Acute NHS Trust;  Gill Harris  - Chief Nurse, Jo Keogh- Divisional Director Women’s and Children’s,

Morag Preston - Clinical Director Obstetrics and Gynaecology,

Cathy Trinick - Divisional Director of Midwifery Services attended the meeting.  The representatives provided members of the Joint Committee with an update in respect of the external review of maternity services that the Trust commissioned in 2014; the resulting development of the maternity improvement plan and the wider review of maternity services.

An external review of nine incidents which had occurred within maternity services (6 neonatal and 3 maternal deaths) over the period January 2013 to July 2014 was commissioned.  The external review team consisted of a Senior Midwife and an Obstetrician external to the Trust. 

The findings of the review of the nine incidents demonstrated that, whilst the maternal deaths did not appear to be the result of deficiencies in care, further scrutiny and improvement was required from the review of the neonatal deaths.  The key themes identified in the external review were:

·         Clinical Risk Management

·         Clinical Leadership

·         Obesity Management

·         Serious Incident Investigations.

On 1 April 2015 the Trust convened the Pennine Acute Trust (PAT) Incident Management Group (IMG) in response to the External Review of Maternity Services.  The PAT Chief Nurse co-chairs this meeting with an external partner, Stuart North, Chief Officer, Bury CCG. 

                     The Trust has developed a comprehensive improvement plan which responds to the review findings, but also incorporates wider learning opportunities following publication of the Kirkup Review into Morecambe Bay Trust (March 2015),  as well as other internal learning from service feedback. 

                  In support of the improvement plan a number of service improvements have been initiated.  To support the development of the improvement plan a ‘buddying’ system with Newcastle was facilitated by our Chief Nurse.  The Senior Team visited Newcastle in July 2015. This was a very positive visit where clinical relationships were developed and good practice shared. 

The development of the Maternity Improvement Plan has become the foundation for further developments within the Directorate.  Following the Birthrate+ review the Trust Board supported and invested in 40 additional Health Care Assistants (HCA) Bands 2 – 4.  There was a significant recruitment drive over a number of days and 40 additional HCA’s were recruited. 

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

In response to a Member’s question; the Chief Nurse reported that the red flag escalation process now adopted in maternity services enables shared decision making and is part of the process for monitoring safety.

In response to a Member’s question in respect of staff engagement in the process, the Chief Nurse reported that staff are invited to attend the weekly improvement plan meetings and have been engaged in the development of the action plans.  Morale was low in maternity services in the summer of 2015, the Trust has done a great deal of work to address this, including the recruitment of 40 health care assistants as a result staff morale has improved.

Following concerns raised by members of the Committee, the Divisional Director reported that there were no internally generated plans to review maternity services however a wider national review of maternity services is currently underway.

In response to a Member’s question, the Chief Operating Officer reported that lessons learned from the maternity services external review has been expanded to other areas within the Trust.  The Chief Nurse reported that, all incidents were now reviewed by the senior management team and themes were identified and acted on quickly.  The new management at the Trust has been the major driver of change.