Learning from investigations

1. Learning from investigations Sue Eardley Strategy Manager, Children and Maternity 4th May 2006

2. Why is Maternity Important? • 650,000 births a year • Most people remember birth experiences • Public health impact – healthy babies mean healthy adults • Unique chance for health to influence • Cost of negligence • Financial • Emotional and psychological

3. Guiding principles of the Healthcare Commission • Our focus is on outcomes for patients, users of service and the public - and on the rights of all to improve their health and receive good healthcare • We will work in partnership with others so as to make the burden of regulation and inspection as light as possible • We will be independent and fair in our decision making, open and consultative about our processes and accountable for our actions

4. Our statutory roles

5. What triggers an investigation? • Someone telling us something is wrong • Things we find out in visits and checks • Problems shown up by complaints • Government or other inspectors asking us to investigate

6. Health and Social Care (Community Health and Standards) Act 2003 • Powers to conduct investigations (of which this responsive review is one type) • Usually investigate when allegations of serious failings are raised • Particularly when there are concerns that the safety of patients might be at risk • Has the authority to do unannounced visits and also if necessary to recommend special measures to the Secretary of State for Health.

7. Key stages of investigation process • Terms of reference • Team selection • Project plan • Stakeholders • Data analysis • Site visits • Action plan • Report

8. Stakeholders involvement • Opportunity for patients, families and carers, and people working in or with the local NHS to comment on issues they believe are relevant to the investigation. Publicised by: • information sheets • media • website • Survey information, interviews and analysis of issues raised

9. Data analysis • Information from trust and others • Stakeholder information from interviews • Interviews on site visits • Observations on site visit • Analysis of statistical data

10. Site visit • Interviews with a cross section of relevant staff, all grades and professions including non clinical staff, also other relevant organisations • Meetings with groups of people • Observations • Team daily debriefing and planning

11. The report • Investigation manager drafts; team comment; analysts and lawyers check, organisations comment on factual accuracy • Report – Healthcare Commission publishes – a public document • Recommendations – on which the organisation and others must act • Action plan – the trust and key partners draw up an action plan • Both the report and the action plan published on website

12. Three Investigations so far… • Ashford and St Peters • Royal Wolverhampton • North West London Hospitals NHS Trust

13. Findings of the NWLH review • Clinical outcomes • Patient experience • Staffing • Management of risk • Use of clinical information • Use of clinical guidelines • Management and leadership • Duty of partnership

14. Clinical outcomes for women and their babies • The number of maternal deaths higher than expected • The rate of perinatal death when compared to other trusts with similar populations not significantly different

15. The experience of women • Refurbishment detrimental to privacy and dignity • Ineffective equipment maintenance system • Limited support for breastfeeding • Provision of bereavement support limited • Translation services inadequate provision • Staff lack of cultural awareness • Poor complaints handling • Unable to prioritise clinical need • Women’s views not influential and weak patient involvement systems

16. Staffing • Motivated and dedicated staff • Chronic shortages of midwives • Difficulties recruiting and retaining doctors and midwives • Inadequate consultant cover on labour ward • Failure to manage conflict and poor performance • Poor working relationships • Absence of effective team working • Culture of bullying • Lack of accountability of referrals • Rate of appraisals unsatisfactory • Inadequate system for recording attendance at training • Attendance at mandatory training unsatisfactory

17. The management of risk • Good reporting and investigation of incidents • Links between maternity and trust systems weak • Inadequate feedback to staff • Not proactive • Not learning from incidents • Poor attendance at meetings

18. Use of clinical information • Recognised inadequacies with coding • Quality of information generally poor • Insufficient time for staff to access computers • Problems with maternity clinical information system • Record keeping and care planning deficits

19. Use of clinical guidelines and audit • Process for developing and accessing guidelines unsatisfactory • Compliance poor and inadequately monitored • No dedicated provision of specialist services for women assessed as high risk • Audit weak

20. Management and leadership • Failure to take effective action about operational pressures in maternity services • Failure to effectively manage the refurbishment project • Further harmonisation of ways of working following merger still required • Not effectively addressed bullying and lack of cultural awareness • Sustained changes in practice not delivered by previous management team • Lack of clinical leadership on labour ward • Impact of financial challenges

21. Duty of partnership • Failure to routinely inform PCTs about serious untoward incidents • Poor information sharing • NW London maternity capacity project • Good public health information could be more effectively used to inform service development

22. Recommendations • Urgent and immediate • Enhance consultant cover on labour ward • Sort staffing for care of women after surgery • Improve access to interpreters • Ensure safe staffing levels • Reduce demand on service • Review operational procedures for women who are overseas visitors / asylum seekers • Review fire safety arrangements • Ensure regular progress reports to trust board

23. Recommendations – clinical outcomes and the experience of patients • Improve communication • Mandatory cultural awareness training • Improve complaints handling • Ensure effective systems of equipment maintenance

24. Recommendations - staffing • Address shortage of midwives • Recruit dedicated labour ward consultants obstetrician, 60 hours labour ward cover required • Eliminate bullying • Improve attendance at mandatory training and record keeping of training

25. Recommendations – risk and other governance systems • Develop effective systems to share learning • Review meetings • New clinical information system required • Audit records • Review use of guidelines and monitor compliance • Improve care for women after surgery • Develop maternity audit plan

26. Recommendations – management and leadership, and partnership • Temporarily commission additional capacity elsewhere • Improve project management of capital projects • Support current leadership team • Ensure effective communication with SHA and PCTs • Engage with local community and ensure services reflect diverse needs of the population

27. Special Measures • Imposed during report writing stage • External clinical leader appointed • NMC separate review • Additional support provided • Damaging to confidence of women • Additional burden of compliance and improvement • Implications for other trusts

28. National Learning from three investigations • Midwifery staffing levels • Medical staff – levels and organisation • People working together as teams and communicating effectively • Weak involvement of women and public • BME women’s experience to be improved • Philosophy of care • Risk assessment • Poor data quality • Training – especially CTG interpretation • Low profile of maternity services • Equipment problems • Guidelines

29. Impact - and the Future • Raised the profile of maternity • Working with investigated trusts • Improved dataset development • New RCOG standards • NMC / Supervision issues • Challenge to Boards • Work with CNST, etc • National Survey • Maternity portfolio benchmarking work • Continued vigilance and communication