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Trust Board Agenda Item 21. Date: 25 November 2015

Title of Report Midwifery Report

Purpose of the report and the key issues for consideration/decision

The purpose of this report is to provide the Trust Board an update on the current position.

Prepared by: Name & Title

Pauline Jones , Director of Nursing and DIPC Diane Swindlehurst, Head of Nursing, Midwifery

Presented by: Pauline Jones, Director of Nursing and DIPC

Action Required (please X)

Approve x Adopt Receive for information

Strategic/Corporate Objective(s) supported by this paper

Na.

Is this on the Trust’s risk register?

No

xYes

If Yes, Score

Which Standards apply to this report?

CQC x NHSLA x BAF Objectives WWL Wheel

Have all implications related to this report been considered?

Yes/No/NA Any

Action Required

Yes/ No/NA

Any Action Required

Finance Revenue & Capital Na. Na. Equality &

Diversity Na. Na.

National Policy/Legislation Na. Na. Patient

Experience Yes No

NHS Contract Na. Na. Governance

& Risk Management

Yes No

Human Resources Yes No Terms of

Authorisation Na. Na.

Consultation/Communication Yes No Human

Rights Na. Na.

Other: Na. Na. Carbon

Reduction Na. Na.

If action required please state:

Previous Meetings Please insert the date the paper was presented next to the relevant group

ECC Audit Committee

Q&S Finance & Investment Committee

Management Board

IM&T Strategy

Committee

HR Committee

NED Other

Na. Na. x Na. Na. Na. Na. Na. Na.

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MIDWIFERY REPORT November 2015

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Background Maternity and Midwifery services at Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) have, until recently, always enjoyed a very good press and are renowned for delivering excellent, high quality midwifery care. However, following a number of complaints and medico-legal cases (predominantly historical), a midwifery review was commissioned in 2012 by the then Director of Nursing, Operations and Performance. A subsequent action plan was developed. Following only limited assurance regarding the implementation of the action plan; a further review was commissioned in 2013 by the Director of Nursing. It was evident that the culture of the service was not compatible with the values and beliefs of WWL and the future direction of the Trust. Introduction This paper aims to set out the story, conclusion and recommendations following the reviews and a very serious mediation session which took us to planning an effective, caring and safer future for midwifery services. It is important to note that this paper concentrates on Midwifery Services and not the whole of Maternity which would include medical staff.

Maternity Services at WWL has excellent facilities including 28 beds in the maternity ward which include 3 single rooms, nine birthing rooms all of which have en-suite facilities. There is a pool room for women who choose to use water for pain relief in labour and birth. The Maternity Triage and Antenatal Day Assessment Unit are located on the Maternity Ward providing day case support to pregnant women.

There is one operating theatre on the delivery suite. The Neonatal Unit (NNU) is situated next door to the delivery suite should any baby need extra care or treatment.

Antenatal clinics are held within the community in GP surgeries, Children’s Centres or home visits can be provided, at the Thomas Linacre Centre in Wigan and at Leigh Infirmary. The Maternity Service also supports women who choose to have their baby at home.

Our Midwifery Services comprises 100 WTE Midwives and 35 WTE Support Workers. The Unit has 3000 births per year and the community midwifery service will provide antenatal and postnatal care to all women in the Wigan Borough which is usually around 3900 births. Neonatal care is provided in the co-located unit at level 2 and for a number of babies on the maternity ward who require transitional care. Babies that require higher levels of care are transferred within the Local Neonatal Network and are then repatriated to the WWL NNU when care is stepped down then these babies will be offered outreach care, from a team of neonatal nurses, in their homes to facilitate early discharge home and transition into family life. The Midwives in the Unit have developed their philosophy for the Service and is attached in Appendix 1. It must be stressed that the service has received immense praise and recognition both locally from the families that have enjoyed an excellent experience and nationally, when it has been at the forefront of practice.

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First Review A number of the recommendations were implemented following the recommendations of the 2012 Review, these included: Rotational programme to support the reduction of the dangerous “silo” working demonstrated by the Reviewer. This was implemented in order to allow for Midwives to receive the identified learning opportunities in each distinct area of midwifery practice. This was to enable the updating of skills and the fulfilment of requirements for registration with the NMC for the midwifery part of the register. The initial rotation of staff was the Midwifery Matrons exchanging areas of responsibility. Band 6 rotation commenced in January 2013 and Band 7 rotation in April 2013. All staff in these groups had their own personal development needs identified and met as part of the rotation. There was also the expansion of the developmental post for deputy team leaders during this time to support the succession planning requirements in the service. The action plan was monitored but it became evident that this was not owned locally by all the midwives. Additionally, in June 2013 concerns were raised regarding the staffing levels in the unit. Midwives use their own staff via NHSP but it was evident that there was poor local management of the situation with many staff working excessive hours and no comprehensive review of staffing levels. There was a level of unrest amongst the midwives that if left unmanaged, could potentially impact negatively on care delivery. An open meeting with all the midwives was held by the Director of Nursing (DON) and Staff Side representatives. The DON offered 121 meetings for midwives wishing to raise concerns privately which were taken up by a number of staff. Given the state of unrest amongst the midwives a second review was commissioned. Second Review Unlike the first review, the terms of reference were to review local leadership of the Unit. It quickly became evident that there was a negative culture in certain sections of the midwifery service. There was discontent with some leadership styles although there was no evidence to suggest there was a negative impact on care delivery. There was a review of leadership style and numerous one to one meetings to explore the issues. The service is now working towards the recommendations from the subsequent review. There has been a change in local leadership due to pre-planned events which allowed for new personnel. To new Midwifery Matrons had been appointed in May 2015. Mediation The second review culminated in a decision to engage key players from midwifery services, the Deputy and Director of Nursing, the Deputy Director of Performance and Operations and Staff Side in professional mediation. This intensive mediation took place in February 2015 which resulted in a commitment to embrace a positive, constructive culture. Everyone

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committed to an agreement which was shared with every member of staff within midwifery services. This agreement re-enforces the values and beliefs of WWL. (Appendix 5). One cannot underestimate the intensity of this exercise and gratitude must be extended to everyone involved. The mediation and subsequent agreement, signed by all concerned was embraced as a very positive way forward. Compliments and Complaints The service receives many compliments both written and verbal. However there remain current challenges (not exclusively midwifery) which include 19 formal complaints for 2014/15. Details for which can be seen in Appendix 2. Risk Management – Clinical Incident Reporting Maternity Services are renowned for robust incident reporting. Please see attached summarised report in relation to clinical incident reporting. Details for which can be seen in Appendix 3. Medico-legal claims The Governance Team are now proactively involved with the interrogation of the claims in progress and new claims that come into the organisation. Any complaints that are substantiated are now settled quickly so that protracted legal fees are not incurred. The Medical Director, Director of Nursing, Divisional Team and Legal Services are in the process of reviewing all medico-legal claims to ensure lessons are learned. A summary of lessons learned will be provided within the Legal Services Report which will be presented at a future Quality and Safety Committee. Additionally, some historical claims have been settled without full and robust input from the clinicians involved. This is no longer the case. Any individual clinician involved in a claim or complaint will have this documented and reported re-validation so that any themes with individuals can be identified. Whilst clinicians are fully supported and human error is inevitable within any clinical service, any competency issue or malpractice will be handled according to WWL policy. Staff has been held to account when appropriate. Theatre Capacity The maternity service has a single theatre that is used for both elective and emergency cases. On occasion there is a need for emergency cases to be undertaken within the main theatre complex. This presents a clinical risk that is currently scoring 12. The Division have plans to mitigate this risk further by running an elective list that is scheduled in the main theatre complex which will free the maternity theatre for emergency use. Maternity Dashboard The dashboard is produced on a monthly basis as part of the performance report. It has recently been highlighted that there a data issue with the dashboard. As Maternity Services

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require different information to that presented to Trust Board, it appears there has been confusion with information being lost in translation. Assurance has been given by the Division’s Governance Team that this does not reflect a deteriorating clinical picture. Urgent work is underway to ensure the dashboard is fit for purpose. WWL benchmarks well with all other maternity providers on most of dashboard indicators. It is planned that our maternity service will participate in the collection and publication of NHS England’s ‘Open and Honest Care’ Maternity indicators which is already in existence for general nursing. It is planned that maternity will come in line with NHS England’s ‘Open and Honest’ care which is currently adhered to in general nursing. Midwifery Supervision Midwifery Supervision is well embedded at WWL. This supervisory model has been subject to a review by The King’s Fund at a national level and the Supervisors who work within WWL are keen to embrace the recommendations of this report. Occasionally, in the past, it has been perceived that supervision feels secretive; especially in relation to complaints/incident management. The supervisors have been incredibly proactive in ensuring that there are robust, transparent processes in place. The Supervisors meet regularly with the Director of Nursing to provide regular updates with regard to their activities. This meeting also affords an opportunity for the DON to brief the supervisors on any organisational, regional or national issues. Midwifery Supervision is a highly valuable function for our service. However, it requires a higher level of understanding within the service in particular and also throughout the organisation. Safeguarding The level of need around the protection of children is well recognised by the service. Excellent support is afforded to the maternity team from the Corporate Safeguarding Team both in regard to child protection and also safeguarding vulnerable adults which are predominantly cases of domestic abuse. Each distinct area of the service has their own safeguarding link who has a greater insight into the relevant issues for their caseload. Recent investment in to the Safeguarding Team by a 1 WTE Midwife has supported the enhanced supervision around safeguarding. This has now been fully implemented by the corporate team and provided robust support to the lead practitioners in each area. The Service also has the availability of a separately commissioned team of highly skilled midwives and support workers who provide care for the most vulnerable families in the area. Unfortunately, a weakness within safeguarding has arisen over the last few weeks with the promotion (outside WWL) of our Safeguarding Lead for Children and the long term sickness of her deputy. Recruitment plans are on track and sickness cover is currently being explored as a matter of urgency. The decision has also been taken to appoint an interim expert to ensure continuity and safety of service.

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The Kirkup Report The Kirkup Report into the finding of the Morecombe Bay investigation have also further offered opportunities for the potential improvement of the service and a draft benchmarking and action plan paper is in the process of gaining internal agreement. Details for which can be seen in Appendix 4. With the new and refreshed midwifery leadership at the right level the Trust has an excellent opportunity to continue to invest in the service to ensure the leadership capacity continues to grow and meet the needs of the ever demanding changes in maternity care provision. This is planned to be supported by higher visibility of senior managers, senior corporate nursing team, executive team, our Governors and Trust Board members. Indeed expressions of interest have been requested from the Governors to be a member of the MSLC. Leadership Safety Walkabouts are planned into the calendar of events and the service is preparing for the CQC assessment later in the year. Maternity will also be part of the next phase of Talk safe roll out and work is currently ongoing to develop the maternity module in the programme. Workforce The positive and energetic workforce will now be enhanced with the recruitment to the substantive Midwifery Matrons as outlined earlier. The recent business case and subsequent investment in the service with this has resulted in the skill mix review that should ensure the service continues to improve. The exciting appointment to the Practice Development Midwife will further improve capacity and capability within the service. A supportive development programme has also commenced with the Head of Midwifery to improve visibility, openness and the departmental culture following the findings of the second review. An organisational development programme is in place within the service. This includes:

Staff engagement pioneer team Leadership development programmes Leadership Values Questionnaire Coaching

Staff engagement pioneer team The team commenced the 6 month programme in February 2015. The initial diagnostic indicated high levels of engagement (86.9%).

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The team have used the toolkit and have chosen to implement weekly comms cells, daily huddles and to actively celebrate success. During national Midwife Day in May, the team identified their Midwife and Midwifery Support Worker of the year. Leadership development All managers within the department have completed or are scheduled to complete relevant accredited leadership programmes at level 5 & 7. This provides networking opportunities, theoretical knowledge and practical application of tools and models in a supportive environment. Leadership Values Questionnaire (LVQ) All the staff at Band 7 and above will be participating in 360 degree appraisal processes as part of the 2015/16 PDR cascade. This will assess the leadership behaviours and styles of those in senior positions against the WWL values. Feedback is received from managers, peers and staff under their management. Coaching is offered where supportive development is an identified requirement. Coaching As the Trust now has a pool of trained coaches, this will be offered to all Managers and participants on the leadership programmes, in addition to leaders whose LVQ results indicate that coaching would be beneficial. Further Successes Infant Feeding The Infant Feeding Team continue to achieve excellent outcomes with those women who choose to breast feed and the continuation rates remains well above national averages. The Service has also been recently reaccredited by UNICEF as a baby friendly facility. Also, the Neonatal Unit was awarded level 2 compliance; with the support of the Infant Feeding and is only the 3rd unit in the country to do so. The Infant Feeding team are also all fully qualified to undertake frenulotomy (tongue tie); this being only one of two services available in the northwest for this procedure. The latter is a Quality Champions Initiative.

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Local Maternity Services Liaison Committee The reinstatement of the local Maternity Services Liaison Committee (MSLC) supported by the CCG will allow for further assurance on any service review. The Life and Work of Martha Hogg The Trust was proud to celebrate the life and work of Martha Hogg and the maternity service is keen to take the learning from this exciting day to plan more celebratory and networking events. Maternity Triage The implementation of the Maternity Triage has delivered huge benefits for both women and the workforce capacity in the Unit. This has been demonstrated by a number of key indicators not least the improvement in one to one care in labour as well as the incumbent normal birth rate. Friends and Family Test The service has been very keen to adopt and utilise the information made available from the Friends and Family Test and is regularly able to ensure up to 30% return rates for the cards. Complimentary letters reflecting excellent patient and family experience are regularly received and responded to accordingly. Future Opportunities As part of the continuous improvement of the service and the research agenda the unit has volunteered to take part as an early adopter of the NHS England’s project, ‘Call to Action’ - “Saving Babies Lives in the North West” (SaBINE) project as well as currently undertaking the AFFIRM trial research both of which are aimed at reducing stillbirths and perinatal mortality. The team is also an active member of the Strategic Clinical Network (SCN) and has been pivotal in implementing and adopting the good practice shared across the network including the Integrated Care Package for families who have had a stillborn baby. There is an excellent and keen appetite for partnership working as demonstrated throughout this paper and this continues with close working relationships within the local CCG but also across Greater Manchester through work being undertaken with the Association of Greater Manchester Authorities (AGMA) on the 0-5 agenda to improve outcomes for young people. Conclusion It is concluded that poor culture, personality clashes and lack of strong leadership led to the deterioration of some standards of behaviour. There have been weaknesses identified within the midwifery services but there was no evidence to suggest these linked to any clinical incident in relation to clinical care. The complaints in relation to staff attitude are totally unacceptable and are being dealt with in line with our HR policies and NMC guidelines. All staff are signed up to the values and beliefs of WWL and any future deviation of this will lead to formal action. There is fantastic energy and commitment to deliver safe, effective care for our families and babies from our midwives.

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Next Steps Midwifery services will embrace the values and beliefs promoted by WWL and endorsed by the mediation agreement. The division will ensure robust leadership is in place and check by using cultural barometers/pulse checks. Leadership walkabouts will also take place. NHS England is undertaking a much wider benchmarking exercise across all maternity units following the Kirkup Report. WWL welcomes this. Ensure robust action plans are in place for maternity and the wider organisation in relation to the Kirkup Report. Supervisors of Midwives will undertake ‘awareness raising’ sessions in relation to the role and responsibilities. Supervisors of Midwives will review the King’s Fund recommendations. The performance improvement action plan will continue to be implemented and will be formally evaluated by the Director of Nursing and Deputy Director of Operations and Performance The staff engagement pioneer team process will complete in August and the team will present at the pass it on event. Current and future leaders within the department will be provided with access to leadership development programmes Leadership Values Questionnaires will continue to measure the behaviours and styles of the management team With the new and refreshed midwifery leadership at the right level the Trust has an excellent opportunity to continue to invest in the service to ensure the leadership capacity continues to grow and meet the needs of the ever demanding changes in maternity care provision. This is planned to be supported by higher visibility of senior managers, senior corporate nursing team, executive team, our Governors and Trust Board members. Indeed expressions of interest have been requested from the Governors to be a member of the MSLC. Leadership Safety Walkabouts are planned into the calendar of events and the service is preparing for the CQC assessment later in the year. Maternity will also be part of the next phase of Talk safe roll out and work is currently ongoing to develop the maternity module in the programme. It was very clear from the mediation process that this service should be allowed to move forward without constant reference to its past. An update report will be presented to the Quality and Safety Committee in due course.

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Appendix 1

MOTHER

Maintaining Offer support Team work Helping Ensuring Research

a partnership between the midwife, the woman and her family throughout the child birthing process a holistic approach, endeavouring to meet the physical, psychological, social, cultural and spiritual needs of the woman, the baby and her family an approach that fully utilizes the knowledge and skill of the midwife to our colleagues, encouraging continuing professional development to student midwives and other learners, aiding the translation of theoretical knowledge into practical skills within the ‘care’ setting liaising and co-operating with other health care professionals as a member of the multi-disciplinary team mutual recognition of the respective roles of those who may participate in the care the woman to make the most suitable choice by ensuring all relevant information is given in an unbiased manner a safe environment which is conducive to effective midwifery care, and endeavouring to promote a friendly and welcoming atmosphere adopting a needs based and/or, when appropriate, a problem solving approach to midwifery care based on current research to keep abreast of current midwifery practice, taking responsibility for personal and professional updating and development

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Appendix 2 Complaints 2014/15 - 19 formal complaints;

Subject

Location

All Aspects of clinical treatment

Oxygen incident during birth Missed diagnosis of blood clot on afterbirth not picked up on scan Premature baby felt to be discharged too soon after birth Labour experience - midwife; post-delivery concerns Birth - baby born in unusual position Mother suffered PSD following traumatic birth Poor labour experience Traumatic labour Attitude of staff at Early Pregnancy Unit Substandard clinical management in pregnancy Substandard care in labour Retained swab

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Communication issue leading to inappropriate correspondence and inaccurate information

Personal record not updated which potentially could have affected continuity of care. Immediate Actions In relation to all these complaints, immediate action was taken. All staff endeavour to deal with all concerns immediately. Additionally, all families are offered a face to face meeting as a matter of urgency. As labour can sometimes be a traumatic experience for Mums and Dads we now offer a post-delivery clinic to allow reflexion of the patient experience. Lessons Learned On review of the Action Plans from the above complaints the following learning points were identified:

  

Learning Point Lead Responsibility Use of Patient Stories

Ward Manager/Matron

Improvement of documentation and communication

Consultant Obstetrician Matron Band 7 Team Leaders SOM’s

Raise awareness of the on-going risk assessment throughout pregnancy, amended and documented in plans of care should a woman change from a low risk to a high risk category

Consultant Obstetrician Matron

Discussion of complaint with staff

Ward Manager/Matron

Review of process for checking blood documentation on request forms and blood samples

Matron

Review of the checking of results and the actions taken on receipt of results

Matron

Review of the checking of results and the actions taken on receipt of results

Matron

To ensure Professionalism is maintained at all times during patient contact

Matron Band 7 Team Leaders SOM’s Consultant Obstetricians

Identify any training needs for Midwives or Doctors involved in care

Matrons Band 7 Team Leaders SOM’s Clinical Supervisors

Evaluating placental completeness All Staff Customer Care Customer Care course for involved staff Re-issue of swab and instrument count SOP to all staff

Head of Governance

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Whiteboards to be drawn up with template and used consistently and effectively in all labour suites

Matron

All items with traceable labels to be filed within the patient notes

Matron

Inclusion of perineal pads as a countable item to be recorded on whiteboard

Matron

Counted swabs to be placed in a separate bag for disposal and same removed to sluice following completion of the count

Matron

Development of suturing workshop Midwives To review the current system of formal process for communication with partner agencies

Head of Nursing

Review processes for both receipt and notification of pregnancy loss with nearby Trusts

Head of Nursing

All the above actions are completed. However, whilst numbers of complaints remain low the service does take them all very seriously, responding and learning from each. The Divisional Director of Performance and Head of Midwifery are in the process of reviewing the action plans from formulated in response to these to ensure the learning has been embedded into practice and can be evidenced accordingly. Following the increased focus on this service, the midwives aim to publicise more widely their positive compliments and letters of gratitude.

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Appendix 3

Obstetric/Maternity Incidents Reported 1 April 2014 to 31 March 2015  

 

From 1 April 2014 to 31 March 2015 a total of 601 obstetric/maternity incidents were reported and investigated. These accounted for 6.5 % of all incidents (9,164) reported within the Trust during the 2014/15 reporting year.

Table 1 below, illustrates incident reporting rates within obstetrics/maternity over the last 3 financial years to enable comparison. There is a slight increase (46) in the number of incidents reported during 2014/15 which represents an 8% increase against the 2012/13 reporting trend but no increase against the 2013/14 figure. Table 1 also illustrates the reported incidents by ‘Incident Type’ over the last 3 financial years. Incident 'Type' changed on 1 April 2014 from Clinical and Non-Clinical to 'Who does the incident affect?’. Whilst it can be seen that the most frequently reported incidents between 1 April 2012 and 31 March 2015 are those affecting patients. The ‘Top 3’ reporting categories for each incident type are detailed in Tables 3 – 6 which can be found in sections 1 to 4 of this report.

Table 1: Obstetric /Maternity Incident Reporting Rates 1 April 2012 to 31 March 2015

Incident Type 2012/13 2013/14 2014/15 Total

Patients (In-patients, Out-patients, Day Case patients) 530 533

Staff (WWL Employees, Volunteers, Students, Agency/Locum) 18 18

Visitors / Contractors / Members of the Public 4 4

The Organisation (eg IT, Information Governance, Services, Premises, Reputation) 49 49

Clinical Incident 504 552 1053

Non Clinical Incident 51 46 97

Totals: 555 598 601 1754

A more detailed breakdown of reporting trends by month during 2014/15 is illustrated below in table 2 below. The highest number of incident reports submitted was during September to December 2014 with numbers then falling during the first 2 months of the final reporting quarter January to March 2015. Table 2: Obstetric /Maternity Incident Reporting Rates 1 April 2014 to 31 March 2015

  2014 04 

2014 05 

2014 06 

2014 07 

2014 08 

2014 09 

2014 10 

2014 11 

2014 12 

2015 01 

2015 02 

2015 03 

Total 

Patients 44 37 35 38 38 55 53 55 52 36 36 51 530 Staff 3 3 0 3 1 2 2 2 0 0 1 1 18 Visitors / Contractors / Members of the Public 1 0 0 0 1 0 0 0 1 0 1 0 4 The Organisation 0 4 8 1 2 7 9 5 2 4 5 2 49 Totals: 48 44 43 42 42 64 64 62 55 40 43 54 601

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Whilst there has been a slight increase in reporting rates on the whole the incident reporting culture within obstetrics/maternity does not appear to be continuing to develop. Recommendation: Consideration should be given to exploring if there are any barriers to reporting amongst staff and also an exercise should be undertaken to compare reporting rates, trends and themes against those of a comparable organisation or an organisation with a comparable number of deliveries per year.

1. ‘Top 3’ Reported Incident Categories Affecting Patients The ‘Top 3’ reported incidents affecting patients, illustrated in table 2 below, account for 88% of all reported obstetric/maternity incidents and because of this the ‘Top 3’ reported incidents affecting patients has been subject to greater analysis to determine key Themes and Trends and recommendations.

Table 3: ‘Top 3’ Incident Categories by Reporting Month & Total Reported

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

2015 03

Total

43 37 35 38 38 55 53 55 52 36 36 51 530 Labour and Delivery 14 10 11 9 10 12 13 11 17 9 8 9 133 Neonatal Event 4 8 5 6 7 8 10 14 10 12 10 9 103 Maternal Event 2 5 4 2 1 5 1 5 6 1 3 4 39

Labour and delivery events are the most frequently reported incidents, representing 22% of all reported obstetric/maternity incidents and 25% of all reported incidents affecting patients. Blood loss >1500mls at labour and delivery account for 28% of all reported labour and delivery event incidents and for between 33 and 50% of labour and delivery event incidents reported May, June, July and November 2014 and also January and March 2015 – these 7 months accounted for 76% of all incidents relating to blood loss >1500mls reported during 2014/15

2014

04 2014

05 2014

06 2014

07 2014

08 2014

09 2014

10 2014

11 2014

12 2015

01 2015

02 2015

03 Total

Labour and Delivery Events 14 10 11 9 10 12 13 11 17 9 8 9 133 Blood Loss >1500mls 1 5 4 3 1 3 2 4 6 3 2 4 38

Recommendation: An exercise should be undertaken to consider if the neonatal unit admission rates per 1000 births are in line with national average and those of a comparable organisation/comparable deliveries per year.

Neonatal events are the second most frequently reported incidents, representing 17% of all reported obstetric/maternity incidents and 19% of all reported incidents affecting patients. Unexpected admissions to NNU for respiratory distress account for 24% of all reported neonatal event incidents and for 50 to 55% of neonatal event incidents reported in June and December 2014 and March 2015 – these 3 months accounted for 48% of all unexpected admission to NNU for respiratory distress incidents reported during 2014/15.

2014

04 2014

05 2014

06 2014

07 2014

08 2014

09 2014

10 2014

11 2014

12 2015

01 2015

02 2015

03 Total

Neonatal Events 4 8 5 6 7 8 10 14 10 12 10 9 103 Unexpected admission to NNU for Respiratory Distress 1 3 2 1 2 0 1 1 5 4 0 5 25

Recommendation: An exercise should be undertaken to consider if the neonatal unit admission rates per 1000 births are in line with national average and those of a comparable organisation/comparable deliveries per year.

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Maternal events are the third most frequently reported incidents, representing 6% of all reported obstetric/maternity incidents and 7% of all reported incidents affecting patients. Third degree tears account for 85% of all reported maternal event incidents and for between 80% and 100% of maternal event incidents reported each month during 2014/15.

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

2015 03

Total

Maternal Events 2 5 4 2 1 5 1 5 6 1 3 4 39

Third Degree Tear 2 4 2 1 1 5 1 5 5 1 3 3 33

Recommendation: An exercise should be undertaken to benchmark the incidence of third degree tears against a comparable organisation/comparable deliveries per year, taking account of a 2014 article posted on the Royal College of Obstetricians and Gynaecologists site which reported that in England the rate of severe perineal tears has tripled from 1.8% to 5.9% between 2000 and 2012.

Never Events - 1 obstetric/maternity incident reported in August 2014, met NHS England Never Event reporting criteria of ‘retained foreign object following completion of a procedure’. This related to a patient who had a forceps delivery with episiotomy and when attending for an appointment at the GP's a swab was found on vaginal examination. The incident was fully investigated and also included in a review, undertaken by Professor Brian Toft, of all the Trust’s reported Never Events. Following RCA investigation of this incident changes have been introduced to the counting and monitoring of swabs used during labour and delivery. There have been no further reported Never Events to date.

2. ‘Top 3’ Reported Incident Categories Affecting the Organisation The ‘Top 3’ reported incidents affecting the organisation, illustrated in table 3 below, account for 8% of all reported obstetric/maternity incidents.

Table 4:

‘Top 3’ Incident Categories by Reporting Month & Total Reported

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

2015 03

Total

0 4 8 1 2 7 9 5 2 4 5 2 49 SSDU Instrument Related Incidents 0 1 2 0 1 1 4 2 0 2 2 1 16 Information Technology & Information Governance 0 1 2 0 0 2 1 0 2 0 0 1 9 Confidentiality and Communication 0 1 1 0 0 1 0 2 0 0 1 0 6 Staffing 0 0 1 0 1 3 1 0 0 0 0 0 6

SSDU instrument related events are the most frequently reported incidents representing 3% of all reported obstetric/maternity incidents and 33% of all reported obstetrics/maternity incidents affecting the organisation.

Information Technology & Information Governance related events are the second most frequently reported representing 2% of all reported obstetric/maternity incidents and 18% of all reported obstetrics/maternity incidents affecting the organisation.

Confidentiality and Communication along with Staffing related events are the third most frequently reported incidents each representing 1% of all reported obstetric/maternity incidents and 12% of all reported obstetrics/maternity incidents affecting the organisation.

3. ‘Top 3’ Reported Incident Categories Affecting Staff

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The ‘Top 3’ reported incidents affecting staff, illustrated in table 4 below, account for 3% of all reported obstetric/maternity incidents.

Table 5: Top 3’ Incident Categories by Reporting Month & Total Reported

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

2015 03

Total

3 3 0 3 1 2 2 2 0 0 1 1 18 Violence Aggression and Abuse 2 2 0 0 0 2 1 1 0 0 0 0 8 Personal Injury / ill health 0 0 0 3 0 0 1 1 0 0 0 1 6 Slips Trips and Falls 1 0 0 0 1 0 0 0 0 0 1 0 3

Violence, aggression and abuse events are the most frequently reported incidents representing 1% of all reported obstetric/maternity incidents and 44 % of all reported incidents affecting staff.

Personal injury and or ill health events are the second most frequently reported incidents representing 1% of all reported obstetric/maternity incidents and 33 % of all reported incidents affecting staff.

Staff slips, trips and falls are the third most frequently reported incidents representing <1% of all reported obstetric/maternity incidents and 16% of all reported incidents affecting staff. 4. Reported Incident categories Affecting Visitors / Contractors / Members of the

Public There are only 2 events reported affecting Visitors / Contractors / Members of the Public and these account for < 1% of all reported obstetric/maternity incidents Table 6:

Top 3’ Incident Categories by Reporting Month & Total Reported

2014 04

2014 05

2014 06

2014 07

2014 08

2014 09

2014 10

2014 11

2014 12

2015 01

2015 02

2015 03

Total

1 0 0 0 1 0 0 0 1 0 1 0 4 Personal Injury / ill health 1 0 0 0 1 0 0 0 0 0 1 0 3 Slips Trips and Falls (Non-Patient) 0 0 0 0 0 0 0 0 1 0 0 0 1

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Appendix 4

The Report of the Morecombe Bay Investigation By Professor Bill Kirkup CBE

Postion Statement and Action Plan for WWL. Draft One. May 2015

Introduction The report was published subsequent to an independent investigation into the management, delivery and outcomes of care provided by the maternity and neonatal services at the University Hospitals of Morecambe Bay NHS Foundation Trust from January 2004 to June 2013. Background This Report details a distressing chain of events that began with serious failures of clinical care in the maternity unit at Furness General Hospital, part of what became the University Hospitals of Morecambe Bay NHS Foundation Trust. The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS. The report found that had any of those opportunities been taken, the sequence of failures of care and unnecessary deaths could have been avoided. As it is, they were still occurring after 2012, eight years after the initial warning event, and over four years after the dysfunctional nature of the unit should have become obvious. The findings are stark, and catalogue a series of failures at almost every level – from the maternity unit to those responsible for regulating and monitoring the Trust. The nature of these problems was serious and shocking, and it is important for the lessons of these events to be learnt and acted upon, not only to improve the safety of maternity services, but also to reduce risk elsewhere in NHS systems. Position Statement The origin of the problems described within the report lay in the seriously dysfunctional nature of the maternity service at Furness General Hospital (FGH). The key issues found that contributed to this were:

Clinical competence was substandard. deficient skills and knowledge working relationships were extremely poor midwives pursued normal childbirth ‘at any cost’ failures of risk assessment and care planning unsafe care response to adverse incidents was grossly deficient repeated failure to investigate properly and learn lessons.

Whilst the service at WWL considers that none of the above applies to the current working within and without the maternity and children’s services, a robust action plan has been formulated for the Trust to assure that the very unfortunate and regrettable position Morecombe Bay trust found themselves in would not occur here.

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Recommendations The report makes 44 recommendations for Morecombe Bay Trust and wider NHS, aimed at ensuring the failings are properly recognized and acted upon. The investigation report detailed 20 instances of significant failures of care in the FGH maternity unit which may have contributed to the deaths of 3 mothers and 16 babies. Different clinical care in these cases would have been expected to prevent the death of 1 mother and 11 babies. The report says proper investigations into serious incidents as far back as 2004 would have raised the alarm. It was not until 5 serious incidents occurred in 2008 that the reality began to emerge. The report’s recommendations are far reaching, with 18 aimed at the Trust and 26 for the wider NHS and other organizations. Many contain specific target dates for completion. Key recommendations for Morecombe Bay Trust specifically include:

an apology to families reviewing skills, training and duties of care better team working better risk assessment an audit of maternity and paediatric services better joint working across its sites forging links with a partner Trust reviewing incident reporting and investigation, reviewing complaint handling reviewing clinical leadership improving the physical environment of the delivery suite at FGH.

The General Medical Council and Nursing and Midwifery Council are recommended to consider investigating the conduct of those involved in patient care. The national review recommended within the report into the provision of maternity and paediatric care has commenced and is led by Baroness Cumberledge. The recommendations go on to call for action from Trusts, professional regulatory bodies, the Care Quality Commission, Monitor, the Department of Health, NHS England, nursing and midwifery organisations as well as the Parliamentary and Health Service Ombudsman. Conclusion In light of the above the following action plan has been developed for WWL to provide the evidence and assurance in regard to the service provision for women, children and families. These plans will be monitored through the internal governance process of the Trust and support sought accordingly.

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ACTION LOG: Kirkup Report May 2015 (draft one)

Recommendation Action Required Desired Outcome Assigned

to Target Date

Date completed

1.All staff with defined clinical leadership responsibilities can evidence appropriate training and development

Clinical Leaders must utilise PDR process to identify requirements, revalidation process will be utilised effectively. Supervision will continue to support safe clinical practice in maternity. Identified learning needs will be met on an individual or collective basis accordingly.

Right people will be in the right place, with the right skills to ensure the safety of the services.

Line Mangers to identified

clinical leaders

Continuous

2.The Trust Board has adequate assurances of the quality of care provided in the specialities. The Clinical Commissioners (CCG) should have assurance that the recommendations from Kirkup have been acted upon. The Trust will participate in the national Review of Maternity Services.

The Trust Governance process should continue to provide robust information to continue to enable the Trust Board to have robust oversight of the quality of services. Information will be provided to the CCG in the requested format. Data will be submitted as/when requested from the National Panel.

Issues identified will be promptly addressed and any work will be prioritised accordingly. Regular reporting will occur. Robust information in regard to Trust services will be provided.

Corporate Governance

Lead

Trust Board

Continuous

Commences April 2015

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3.Middle Managers, Senior Managers & Non Executives have clarity in their roles in relation to quality.

Appropriate guidance and training should be provided as required.

Each staff group is confident in their own responsibility and contributions to the quality agenda.

Organisational Development

Team

Continuous

4.National Standards will be set for Clinical Leads at all levels. (Heads of Service, DoNs and MDs). National protocol setting duties for staff attending inquests.

A programme of training will be devised when the national standards become available. The current in house support provided to staff will continue until national protocol is available.

The Trust will be able to provide CQQ with evidence of policies and training undertaken.

Organisational Development

Team

To be confirmed

5.To enhance collaboration and communication with the Neonatal Unit and Maternity Unit

A representative from NNU to attend the weekly Maternity Service Comm Cell and maternity Clinical Issues Group. NNU com cell will be developed with Maternity staff in attendance All bands 6 and 7 NNU staff to attend leadership course Audit to be undertaken regarding Term admissions of babies to the NNU as there appears to have been an increase of these and we would like to investigate the reasons for this. This will also be a CQuIN for 2015/16.

Enhanced communication and team working across the Maternity and Paediatric Service. To provide consistent, strong leadership Identification of any themes or trends in the admissions and therefore a reduction of term baby admissions to the NNU

All

NNU Lead

Nurse

Midwives, NNU Lead

Nurse

May 2015

June 2015 April 2015

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6.To enhance communication links between hospital and community maternity service’s

Development of the Maternity service weekly Communication cell with representation from all areas of the service. Ward receptionist/ clerks to work across the whole maternity service. The community clerk to be based on the Maternity floor.

Enhanced communication across the service. Increased team performance, service delivery, communication and information sharing.

All

Matrons

May 2015

July 2015

7.Involvement of all midwives & Nurses in the Governance process/ framework.

Facilitation of off duty rostering to allow all midwives and senior NNU staff the opportunity (in rotation) to attend monthly Governance meetings. Clinical Cabinet and Clinical Issues to be the priority. 12 month plan of attendance to be devised. Prior to attendance at Clinical issues the staff will be asked to review 2 incidents (with support) and to present these at the meeting.

Regular representation of staff groups at the Governance meetings. Increased awareness and engagement in the Governance processes to further support provision of safe, effective services.

Team Leaders

Team Leaders and Matrons

Sept 15

8.To ensure robust Datix completion continues and the subsequent review of these incidents remains to a high standard.

Increase Team leader/ manager involvement in incident investigation and review. Ensure all Midwifery & Nursing managers have access to Datix and are able to review and investigate incidents. Provide further training to those who require it.

Team leaders/ managers will be more confident and able to be involved in this process. Development of managerial skills and also an increased awareness of the processes required.

Matrons And Team

leaders

April 16

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Clinical Managers to continue to access support from Governance Lead and Q and S midwife in Datix management and incident review/ investigation, so that any gaps in knowledge can be identified and addressed. Development of a Core group of midwives and nurses to also take part in Datix review, investigation and feedback for staff.

Learning and workload shared. Robust processes are in place to ensure that investigations into serious incidents are undertaken in a timely manner and that they enable shared learning at local and/or national levels as appropriate. Serious incidents will not be open beyond deadlines so that assurance of appropriate action has been, or is being taken. This will ensure safeguarding of patients and allow staff to understand the impact on individual patients and/or staff.

Governance Lead

9.Learning from Complaints, Litigation and incidents

Involving staff in complaints reviews and RCA investigations. Sharing outcomes for learning with all relevant staff and identification of any themes will continue. Providing training and development opportunities when issues have been highlighted. Work closely with practice development Midwife and Nurse to provide a safe learning environment where lessons learnt can be cascaded. The Trust should consider introducing external scrutiny of complaints as well as the involvement public and patient in resolving complaints further. By way of

Risk of issues reoccurring will be minimised. All senior NNU staff to attend RCA training Duty of Candour and Raising Concerns will be adhered to.

Governance

Lead

Practice Development

Nurse & Midwife

Patient

Relations Team

MSLC

July 2015

September 2015

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the Maternity Services Liaison Committee.(MSLC) Any requirement for external review of a service will meet with National guidance.

Learning will be collated and disseminated to other Trusts.

Corporate

Governance Team

TBC by Monitor and

CQC

10.Maintain a robust Audit Calendar with Multi-disciplinary participation.

Utilise clinical audit as a measure for improvement. Ensure all clinical staff participate in audit process. Identify relevant audits from actions within clinical incidents. Identify any themes and trends within incidents complaints and claims.

Clinical audit provides a method of systematically reflecting on and reviewing practice. Identifying and promoting good practice will lead to potential improvements in service delivery and outcomes for mothers and infants.

All Staff

Audit Leads

Continuous

11.Utilise improvement tools and measures to inform practice

All areas are participating in AQI audits with the exception of antenatal clinic (not applicable to this area).Relevant indicators will be developed with the staff from this area to measure performance in key aspects of antenatal care. All other areas are committed to ensuring completion of their data within the relevant time scales in order to discuss in real time at Clinical Cabinet and other relevant forums. Maternity safety thermometer to continue for delivery and postnatal care. Quality Impact assessment will continue for all service changes proposed. Peri-natal mortality meetings will

Delivering a set of quality standards which define and measure good clinical practice.

Improvement in outcomes measures and patient satisfaction.

Standardising aspects of care may improve recovery and management of conditions. Systemic review and recoding of all perinatal deaths will continue. Independent scrutiny can be considered.

Quality and

Safety Midwife

All relevant managers

CDs M

Continuous

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continue and will include stillbirths and deaths after transfer to other Units.

12.Aim to be within the top 10% of all Trusts for Quality and Safety

Continue to bench mark ourselves against other organisations and monitor outcomes with the continual aim of improving practice and outcomes for mothers and infants by: Maternity Dashboards Regional Dashboards Doctor Foster intelligence National reports and outcome measuresNICE Quality Standards.

High-performance will be maintained by way of the culture of continuous improvement.

Governance Lead

Continuous

13.Production of the annual Governance report

Individual areas will submit progress reports on key performance within their area, outing recommendations and actions for year ahead. Key Outcome measures and activity within the service will be included within the report. Plans for improvement measures to further enhance quality and safety and patient experience will be formulated.

To share with staff and the wider Trust outcomes, activity and governance arrangements within Maternity Services. Highlighting good practice within individual areas and plans for continual improvement going forward into 2015/2016

Governance

Lead

Consultant Obstetrician

Annual report date June 2015

14.Re convene Joint Maternity and Paediatric Senior management meetings

To encourage collaborative working across teams

Seamless Governance arrangements across both specialities.

Head of

Midwifery

May 2015

15.Training and Development is aligned to learning needs identified within the service.

Training and development opportunities are allocated equitably across all disciplines. Core training is in place for all staff with

Safe maternity and NNU teams have staff with the right skills, which will be achieved by staff having the right training and resources to work effectively

Practice

Development Midwife &

Nurse

Continuous

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monitoring of attendance. The Maternity Training needs analysis (TNA) is reviewed at least annually. Competencies are developed within relevant areas with passport certification. Trust E learning programmes are completed as relevant by all staff groups. Opportunities for multi-disciplinary training will be developed between Maternity and Paediatric services.

together as a team.

t Head of Midwifery

Governance

Lead

August 2015

16.Supervisors of Midwives to contribute to the governance processes within Maternity Services.

Supervisors will be represented at all governance meetings. Supervisors will be involved in incident and complaint investigations. Supervisors will provide assurance to the Head of Midwifery how they are contributing to the quality and safety agenda. Supervisors of midwives will ensure that all investigations are undertaken in a timely manner and completed in 45 days in line with the LSA standard. Minutes of clinical cabinet and governance meetings will be embedded in Supervisor’s meeting minutes.

Supervision of Midwifery to remain integral to the governance agenda and promoting and supporting best practice Regular communication will ensure safety of the service.

All Supervisors of

Midwives

Ongoing

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Quarterly meetings between the maternity managers and supervisory team Supervisors will be involved in the re-launch of the Maternity Services Liaison Committee, as a forum for service users. Other means of engaging with service users will be explored

There will be forums available in which women’s views on their maternity experiences can be voiced and actioned appropriately.

August 2015

17.To raise the profile of Supervision within the Trust

Survey monkey of maternity staff’s and management’s perception of the role of supervision will be developed and undertaken by Supervisory team. Management invited to annual Local Supervising Authority audit visit presentation and feedback. Quarterly meetings to take place between DoN, HoM and contact Supervisor, following the submission of the quarterly report to DoN. Business plan has been agreed in relation to time and resourcing to undertake Supervisory role.

Supervision is visible and high on the Trust agenda, and it’s value and contribution towards the safety of mothers and babies is recognised by key individuals within the Trust. Formal feedback received on business case.

All Supervisors of

Midwives, HOM, DON

DDoP

June 15

July 15

June 2015

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Appendix 5 Action Plan following Mediation

(Leadership and Culture) Recommendation Action to be taken Evidence of completion Date to be

completed Date

completed 1. Improved Communication

Weekly Comms Cell will be established. Prioritise attendance and take a

lead on the comm cell. Hold overall responsibility for

ensuring that representation from each area is available or info is cascaded by attendees.

Datix incidents and near misses to be discussed.

Chairpersons reports to be brought to the comm cell

Information to be cascaded through attendees to huddles.

Minutes will be made available. Huddles will be in place and feed into weekly comm cell. Pertinent agenda items will be discussed at one to one meetings.

23.3.15 31.10.15

Escalation of concerns in a clear and concise manner, explaining expectations of the outcome and providing details of all potential solutions with benefits and risks.

Escalated concerns to and solutions offered to be supported by line managers. Feedback provided regularly by line managers on performance.

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To open Yammer account regular cascade of information

from Comm Cell will be provided as an alternative to huddles for staff to access

Comments from all staff on site 13.3.15 13.3.15

Face to face contact with all midwifery areas. Monthly 1 – 1s with direct

reports to allow formal time to ensure performance is acceptable.

-Monthly meeting in each clinical area to ensure clear communication is occurring from Comm Cell.

This will allow for : Supporting the shared values

based on the principles from the mediation.

Being held accountable and hold to account individual’s actions from preceding meeting.

Encourage challenging and uncomfortable questions.

Build effective relationships by giving and receiving feedback

Congratulate success. Apologise when things go

wrong.

Diary management will be effective. Comm cell KPIs identified ( as per agenda items)

4.4.14 5.3.15

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2. Improved Leadership

There will be defined meetings which require HOM attendance and which meetings can be delegated. Remain accountable for receiving and providing feedback. Develop staff by demonstrating trust through delegation. Ensuring it is appropriate to delegate tasks to someone and that they have the capacity and capacity to undertake the task. Contribute at team meetings, encouraging constructive conflict without criticism Remaining accountable and responsible for ensure a clear chain of command.

Diary management will be effective. Effective leadership from all levels of staff. Effective delegation and development of Matrons and Divisional Manager

31.1.16

Package of leadership development for whole service to be devised and supported by RCM Ensure all band 6 & 7 managers attend WWL leadership programme

Staff will demonstrate effective awareness of leadership skills at all levels. All staff side bodies will be welcome and have a presence in the service.

Meeting arranged for 1.6.15

Attend relevant events and develop Midwifery and Children’s network and networking links. Bring ideas back to the Division.

Implementation of recommended practice e.g. SaBINE project.

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3. Recruitment and selection

Current pivotal vacancies to be recruited too

- Maternity Matrons post to be re-advertised

- Training and Development Lead to be advertised

- Band 6 Managerial Development role to be developed and advertised

Closing date 2.4.15 Shortlisting 10.4.15 Interviews 26.5.15 Closing date 10.4.15 Shortlisting 21.4.15 Interview dare TBA Job Description reviewed 22.4.15 Posts advertised TBA Roles recruited to (plan for August commencement) .

12.3.15

In progress

4. Improved Induction All new starters will receive an effective and informative orientation and induction Lead, with support from Head of Professional Practice, a survey and focus group to review the current local induction and orientation process, and implement any changes

Feedback from new starter forms 31.8.15

5. Appropriate and effective PDR process which identifies staff development

Ensure all staff receives appraisal training. This should be extended to include an information session for appraises.

Evidence of all staff attending on Moodle

31.10.15

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6. Pioneering Team project Proposal that all staff will have an identified and named person who will lead a 1:1, will be offered as part of listening event. As part of the Pioneer Teams Project, with the acting matrons identify and lead a project to improve staff engagement in maternity services with SMART objectives, focusing on getting the right things done.

Should staff agree to proposal, monitoring of % 1:1s undertaken on maternity dashboard or comm cell Improvement in pulse checks.

30.6.15

30.9.15 31.10.15