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

Learning from investigations

Sue Eardley

Strategy Manager, Children and Maternity4th May 2006

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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

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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

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Our statutory roles

Assessment of the provision of health care, including public health, in the NHS & independent sectors

Annual ratings for NHS trusts

Regulation and annual inspection of independent healthcare

Consideration of complaints which NHS trusts have not resolved

Investigations into serious service failures

Coordination of healthcare inspection by others

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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

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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.

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

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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

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Data analysis

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

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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

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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

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Three Investigations so far…

• Ashford and St Peters• Royal Wolverhampton• North West London Hospitals NHS Trust

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Recommendations – clinical outcomes and the experience of patients

• Improve communication• Mandatory cultural awareness training• Improve complaints handling• Ensure effective systems of equipment

maintenance

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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

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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

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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

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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

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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

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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

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