University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) has published a Maternity Learning Review report, following the commissioning of an independent review into a number of maternity incidents taking place at the Royal Derby Hospital from January 2021 to May 2022.
Overall, the review does not identify from the evidence provided or through further observation any information requiring escalation to relevant authorities. It identifies “no common themes that directly impacted on all outcomes” and states: “It is not possible to know if a different approach to safety investigation and implementation of learning, or a different safety culture within the maternity unit, could have influenced a different pathway of care prior to the critical events.”
In terms of areas for improvement, the review highlights inconsistencies in guidelines between the two maternity units at the trust; periods of fragmented leadership with many changes in the leadership structure; and a significant staffing gap, among others.
A number of safety recommendations have been made where review findings were considered to contribute to one or more of the events.
Opportunities and recommendations
The review emphasises the importance of ensuring that there is a clear process for declaring incidents such as a massive obstetric haemorrhage, and that following an emergency call a cascade of notification alerts are in place to support safe and timely provision of care.
The trust is to follow national guidance for the use of a universal 2e22 call for emergency calls, and to ensure that communication and support continues in the postnatal period.
In addition, a “robust rapid review” is to take place following a patient safety event, involving the woman and family wherever possible, to identify opportunities for learnings and improvements.
The review also notes a need to improve the consistency and clarity of guidance and make sure documentation is completed thoroughly.
“Staff need to feel that their leadership teams are kind, compassionate and lead by example,” the review states. “Staff benefit from feeling the wider multi-professional team is pilling in the same direction.”
It goes on to suggest a number of prompts for the trust to follow with regards to safety, such as: what leadership training and coaching is the trust providing? Is there an opportunity to improve and increase multi-professional learning to allow teams to develop relationships? Can the trust engage with staff to learn how they navigate guidelines, where they find them, and any barriers they face?
Improvements in place
In terms of what the trust has already done, the review notes that they have met with the Civility Saves Lives national campaign team to analyse the support and training staff can access. They have also started a review into the holistic care that is provided to women and are to explore more opportunities to increase their bereavement support, and to create a family liaison officer.
The review highlights that the trusts have revised their major haemorrhage guidance and established a “more robust process in place for monitoring compliance with the guideline.”
They have also enhanced their “existing-incident process to ensure completion of 72-hour reviews” which follows a series or moderate incident, including a panel that analyses initial findings, through which learnings can be developed.
In addition to this, the trust is using the national Patient Safety Incident Response Framework (PSIRF) managing incidents. Within this they have created a “project implementation group” looking at how they can better reach family and patient involvement.
The trust has recruited two new consultants; 18 new midwives that are from overseas; and appointed retention midwives to work with staff at a closer level to develop and support their careers.
To view the document in full, click here.
