Maternity Report

Maternity ReportPerinatal Quality Surveillance Highlight Report

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Penny Snowden, Director of Midwifery

On behalf of Jo Bennis, Chief Nurse

20 September 2021

Operations Workforce Finance Strategy GovernanceQuality

Purpose of ReportThis report summarises maternity quality performance in 2021/22 and incorporates all nationally agreed Trust Board Metrics

This reports covers the current position on clinical outcomes for women and babies and performance against the national safety agenda.

This report is scrutinised by the Quality Assurance Committee. The strategic objectives are to deliver full compliance with regulatory quality indicators and the national maternity patient safety, quality and experience indicators

Equality and Diversity Impact: The maternity service provides responsive care to all individuals equally; however, it is know that some women from a BAME background do have a higher risk for poorer outcomes hence this is a core theme through the maternity improvement plan.

This report can be released under the Freedom of Information Act 2000.

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Contents

Executive Summary 3

Maternity Dashboard 4-7

Exception Reporting 8

Covid-19 Update 9

Maternity Workforce 10-13

Staff Feedback 14-15

Maternity SI’s and HSIB Cases 16-17

Maternity Incidents Moderate and above referred to

Weekly Rapid Review

18

CNST Year 4 Update 19

Ockenden Update 20

Learning 21

Multi Professional Training Compliance 22


Successes

Key

Messages


• Recruitment of Consultant Midwife

• Application made to the national international recruitment for midwives fund

• Two Consultants Miss Steel and Mr Lumb retired after many years at Peterborough

• Gap Analysis against Year 4 Maternity Incentive Scheme Completed

• Maternity Staffing remains challenging due to COVID Absences, Vacancies, and Maternity

Leave requiring to isolate earlier in pregnancy

• Weekly system calls continued during August

• Home Birth Suspended during August due to significant operational pressures. Weekly

oversight of midwifery staffing by Executive Team in place

• Number of Covid Positive Women increased to match the peak in Wave One

Emerging

Issues

• Increasing numbers of pre terms births from average 6.6% (January-March 2021) to 7.8%

(May-July 2021) and 9.85% for August 2021

• Increased CSR from average 30.83% (January-March 2021) to 34.8% (June-August 2021)

resulting in increased LOS.

• 12 set of twins born in August 2021 against a monthly average of six.

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Maternity Dashboard 2021/2022

Green Amber Red

Births 4850 per

annum for PCHYTD +/- 10% EPR 4387 4355 4339 4338

Births 2200 per

annum for HHYTD +/- 10% EPR 2049 2070 2110 2109

Births (Monthly)

Total babies born (live or

stillborn) in all settngs at

least 24+0 completed

weeks

EPR 581 541 557 Total 352 205

Bookings (monthly) Total bookings EPR 649 576 630 Total 422 208

Bookings (1st visit,

10+0)

% Women booked by 10+0

weeks gestation. All

bookings regardless of

when referral was

received. Excludes formal

transfers of care.

MSDS 68% >90% <90% EPR 89.82% 86.75% 83.95% 86.2% 81.7%Rag rated red at HH and Pansite. Community staffing

issues. High risk on risk register.

Spontaneous Vaginal

Delivery

% NVDs in Term singleton

pregnancies

MSDS averages

55%≥55% <55% EPR 54.25% 53.45% 55.15% 55.90% 54.4%

Overall RAG rated green. RAG rated red HH site and HH

SPC showing cause for concern. Drop in NVD rate due to

increase EMCS. Consultant midwife has been appointed.

Awaiting start date.

Home Birth

Planned homebirths, BBA

excluded. Out of all women

giving birth

>2% <1% EPR 1.64% 1.74% 0.00% 0.00% 0.0%

Homebirth service suspended PAN site due to ongoing

staffing complexities speciaifcally communiyt. Homebirth

service reviewed daily at opertaions meetings. Plan to

progress reopening with case by case basis.

temporarility suspended homebirth service.

MLBU Birth

% Term singleton vaginal

births in a Midwifery led

unit.

>20% <15% EPR 11.67% 12.83% 14.00% 11.00% 17.00%

SPC shows no cause for concern. Rag rated red pansite

for past 3 months, increasing trend evident. MLBU

provision impacted by acuity of Delivery Suite and labour

ward. Significant increase in CS rates also contributory

factor.

Induction of Labour

% Term singleton labours

medically and/or surgically

induced

NMPA national

average 30.8%. <30% >33% EPR 28.30% 30.30% 24.85% 23.90% 25.8%

Ventouse & Forceps

% Overall instrumental

vaginal delivery for Term

singletons

MSDS figures

11.5%≤11.5% >14.5% EPR 10.30% 12.30% 10.05% 10.80% 9.3%

Total Caesarean

Section Rate

% Total caesarean section

in singleton term women

25% UK target

MSDS figures Total

CS 29%

≤29% >32% EPR 35.40% 34.22% 34.80% 33.30% 36.3%

SPC common casue variance on both sites. RAG rated red

for NWAFT for last four months. Deep dive underway.

Singnificant descrease in PCH rate this month (July

>40%).

Jul-21 Comment

Rolling Birth rate for NWAFT 6447

KPI Narrative Aspirational TargetThreshold Data

Source SPCHHPCHAug-21Jun-21

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Green Amber Red

Elective Section Rate

% Total elective caesarean

(grade 3 and 4) in

singleton term women

MSDS figures 13% ≤13% >15% EPR 17.10% 16.20% 14.05% 16.00% 12.1%

No cause for concern on SPC; however been above target

consistency so deep dive being undertaken. RAG rated

amber overall. PCH remains red although decrease since

July evident. An audit of woman's choice with regards

mode of delivery post previous CS in progress.

Emergency Section

Rate

% Total emergency

caesarean (grade 1 and 2)

in singleton term women

MSDS figures 16% ≤16% >18% EPR 18.30% 18.02% 20.75% 17.30% 24.2%

PAN site cause for concern high on SPC. Deep dive in

progress. Decrease in PCH rate howver significant

increase at HH

Seen within 30mins

attendance to triage

Exclude MLU/RAG rated

red>95% <75% Inpt Lead 82.00% 76.50% 100.0%

NEW SPC -

TREND

Figure based on assurance books at PCH, continued

documenation issues - 12% not seen within 30 mins and

35% not documented. Issues a with data capture have

been esclated to triumverate. BR + stats identify 96% with

only 9 eslcalations. Deep dive in progress with

improvement in data quality being the main focus. Case

review of triage admission also due to commence.

Number of women

smoking at the time

of booking

% women smoking at time

of booking

Cambs rate

demographically similar to

national average

MSDS 12% EPR 10.62% 12.08% 12.50% 14.00% 11%

Number of women

smoking at the time

of delivery

% Women idenitified as

smoking at time of delivery

SBLV2 - Reducing

smoking in pregancy will

reduce prem del rate.

MatNeoSIP (2019) state

mandatory field booking

and at delivery.

MSDS 10%, ONS -

our CCG 11.8

Smoking in pregancy

challenge group -

ambition <6% in

2022

≤12% >14% EPR 9.50% 10.50% 11.00% 14.00% 8.0%

Unit Closure 4 6 6 4 2All due to staffing and acuity. Each closure reviewed via

DATIX. No eivdence of harm as a result of closures.

Internal divertNo datix completed. Need more accurate way of

measuring

Midwife/birth ratio

NWAFT01:23 01:28 HoM 01:39.3 01:37.3 01:37.3

System Calls in place to discuss activity, acuity and staffing

during the week and at weekends. Funded at 1:28 as per

phasing of staff investment plan

Supernumerary

status of co-

ordinator PCH

% of shifts where the band

7 is supernumerary for the

whole shift

100% <100% Inpt Lead 84.85% 89.75% 85.95% 89.30% 82.6%NEW SPC -

TREND

Sourced from BR+

Significant risk on Risk Register. Improvement Plan in

place with trajectory of March 2022 for achievement.

Interdependency with Staffing Levels and acuity.

1-1 Care in LabourExclude out of area, BBAs,

Cat 3 and 4 CS 100% <100% EPR 96.60% 94.50% 96.35% 96.80% 95.9%

On risk register. SPC variation showing cause for concern.

Improvement Plan is in place with trajectory of March 2022

for consistent achievement

Jul-21 CommentKPI Narrative Aspirational TargetThreshold Data


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Green Amber Red

ITU Admissions in

ObstetricsSingle organ support 0 ≥1 DATIX 0 0 1 Total 1 0

COVID postive, transferred from ITU to maternity at 29

weeks then transferred back to ITU for onngoing

management

PPH ≥1.5L

% Women blood loss

greater than or equal to

1500mls in term singleton

deliveries

<3% >5% EPR 2.38% 2.41% 3.28% 4.90% 1.65%

3rd and 4th degree

tear

% Number of total women

giving birth

Target <3%.

NMPA 3.5%≤3.5% >5.5% EPR 1.97% 2.37% 1.22% 1.44% 1.0%

Maternal

readmissions

% Term and post term

singleton women

readmitted overnight with

42 days from delivery

(In accordance with NMPA)

National average

3%<3% >3% ETRACK 2.23% 2.58% 1.23% 1.96% 0.5%

NEW SPC -

TREND

PCH: 6 women: 1 BP, 1 PE (later maternal RIP), 1 blood

patch, 2 UTI, 1 infection

HH: 1 woman ? DVT

Maternal Deaths

Number of maternal

deaths that occur during

pregnancy or within one

year of birth (direct or

indirect). Deaths are

attributed by place of death

and to a given month

based on when the death

was detected (not date of

death). Include narrative of

0 ≥1 DATIX 0 0 1 Total 1 0NEW SPC -

TRENDPE 3 weeks postnatal. HSIB undertaking investigation

Number of SI's DATIX 1 1 3 Total 3 0

RIP baby discharged with wrong parents

29 week baby born in poor condition

Maternal death

Never Events 0 ≥1 DATIX 0 0 0 Total 0 0

Suspected or

Confirmed HIE 2 or 3Number of cases 0 ≥1 NICU 1 1 0 Total 0 0 Just term infants? Requires discussion

Mag sulphate

compliance of

appropraite births

% Preterms (<30/40) that

received mag sulphate

SBLV2 & NNAP look at <30

weeks

PRECEPT

standards 95%≥95% <95% Precept NA 25.00% 100.00% 100% NA

NEW SPC -

TREND

Agreement at MLB to change reporting to monthly, not

rolling figure

All applicable cases given in august - 100% (4/4 PCH, 0/0

HH)

AN steriods

% babies born 23-33/40

received at least one 1

steroid.

(NNAP standard)

CNST standard

85%≥85% <85% ATAIN Lead 75.00% 73.35% 100.00% 100% 100.0%

NEW SPC -

TREND

Agreement at MLB to change reporting to monthly, not

rolling figure

All applicable cases given in august - 100% (8/8 PCH, 3/3

HH)



7


Green Amber Red

Unexpected

admissions to NICU

% of all term and post term

deliveries (number taken

from datatbase)

NHSI figure 5% <5% >6% Badger.NET 4.42% 4.51% 4.40% 3.47% 5.3% No transitional care at HH. On maternity risk register

ATAIN

% of all term admissions

reviewed at ATAIN meeting

within 4 weeks of

occurence

>95% <90%Risk

Team 100.00% 100.00% 71.50% 100% 43.00%

NEW SPC -

TREND

HH- 3/7 cases reviewed within 30days - 11 cases in total

with further 4 cases for review still within 30days All to be

reviewed on 23/08/21 - Due to acuity and staffing

Anticipated compliance for Aug is 64%

How many term

admissions were

avoidable

ATAIN target <25%

avoidable <25% >25% 23.65% 3.57% 8.35% 17% 0%

NEW SPC -

TRENDHH based on 3 cases reviewed

Pre-Term deliveries

<37/40

Number of premature

deliveries out of total birth

National aspiration

(SBLV2) aim to

achieve 6%

<6% >8% EPR 10.50% 8.00% 9.85% 10.50% 9.20%SPC shows no cause for concern. 1/3 premature babies at

HH were twins.

Stillbirth rate

Rate per 1000 total births.

Babies born after 23+6

weeks gestation showing

no signs of life. Exclude

terminations. 12 month

rolling.

MBRRACE average

3.5 (2018) <3.9 >3.9

Perinatal

mortality

Midwife

3.75 3.61 1.79 2.8 0NEW SPC -

TREND

PCH: 1 SB in August

HH: 0 SB in August

Agreement at August MLB to change to monthly stats, no

longer to use rolling figures.

Intrapartum

Stillbirths

Number of stillbirths 24+0

completed weeks or more.

Perinatal

mortality

Midwife

0 0 0 Total 0 0

Early neonatal death

rate

Early NND within 7 days.

Rate per 1000 live births.

Exclude <24/40 and

terminations.

MBRRACE

1.12 (2017) <1.12 >1.12

Perinatal

mortality

Midwife

0.15 0.15 0 0 0NEW SPC -

TREND

No NND in July

Agreement at August MLB to change to monthly stats, no

longer to use rolling figures.

PMRT Reviews not

stared, completed

and parents involved

within 4 months

Early neonatal death

investigations started,

completed and parents

involved.

CNST target 95% 0 >1

Perinatal

mortality

Midwife

0 0 0 Total 0 0NEW SPC -

TREND

Skin to Skin

% term babies who had

skin to skin contact

initiated within 1 hour of

delivery.

Maternity Services

Data Set (MSDS)

57%

≥82% <80% EPR 71.6% 78.3% 74.5% 71.60% 77.40%NEW SPC -

TREND

RAG rated red. National Average on MSDS is 57%.

Improvement activities including Skin to Skin in Theatres,

UNICEF 80%. Gaps in BF team on risk register. PCH SPC

cause for concern.

Intention to

breastfeed and did

% women who intended to

breastfeed at booking and

babies that went on to

receive breastmilk at

delivery.

≥95% <90% EPR 82.9% 86.1% 85.0% 82.90% 87.00%NEW SPC -

TREND

Risk identified. Depleting members of BF

team and support workers may have contributed to this.

Has been uploaded onto risk register.

Breast feeding rate

at Delivery

% babies that received

breastmilk at delivery NHS digital 72% EPR 58.8% 66.4% 60.8% 58.80% 62.80%



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Exception Reporting

IndicatorDate

rangeTarget

Current

Aug 21

Average

(rolling

quarter)

VarianceSpecial

causesComments on red RAG rating/variance concern

Booking first visit

<10+0 90% 83.95% 86.84%PCH 86.2%

HH 81.7%

SPC cause for concern low, Rag rated as red overall pan site for last three months.

Decreasing trend. PCH RAG rated red for first time. Impacted by current community

midwifery staffing challenges. On the Maternity risk register as a high risk. Mitigation

plan in place – relocation of rainbow team to help with community workload.

Homebirth 2% 0% 1.13%PCH 0%

HH 0%

SPC shows cause for concern low. RAG rated red pan site. No homebirth on either site

in August due to suspension of homebirth service due to significant staffing challenges.

Service has since been reopened on case by case basis.

Midwife Led Birth

Unit births20% 14% 12.83%

PCH: 11%

HH: 17%

SPC shows no cause for concern and slight increasing trend. RAG rated amber at HH.

MLBU provision impacted by acuity of Delivery Suite and labour ward. High CS rates

also contributory factor.

Total CS rate 29% 34.22% 34.8%PCH:33%

HH:36.3%

The total caesarean section rate has met a red rag rating for the last four months..

There has been a significant drop in HH rate from July which was over 40%. HH has

increased from 28%. Overall Pan site rate similar to July.

ELCS RAG rated Amber. EMCS shows cause for concern high.

A review of the PCH CS from July has been undertaken.

A new birth choices from has been devised for counselling women using Montgomery

principles regarding VBAC.

The top 3 indications for elective caesareans are previous CS, maternal request and

breech presentation accounting for 73% of ELCS. These have remained unchanged.

The top three indicators for emergency caesarean were presumed fetal compromise,

delay in the first stage or labour and delay in the second stage accounting for 72% of

EMCS.

EMCS rate 16% 20.75% 19.02%PCH: 17.3%

HH: 24.2%

Midwife to Birth

ratio 1:23 N/aPCH:

HH:

SPC shows cause for concern. Ongoing midwifery staffing issues reflected nationally

as well as locally. Ongoing recruitment drive. Working with HR to maximise this.

System Calls in place to discuss activity, acuity and staffing during the week and at

weekends. Funded at 1:28 as per phasing of staff investment plan. Newly qualified

midwives due to start in October.

Supernumerary

status of co-

ordinator 100% 85.95% 86.85%

PCH 89.3%

HH 82.6%NEW SPC

Sourced from Birthrate plus. Uploaded to Risk Register. Improvement Plan in place

with trajectory of March 2022 for achievement. Interdependency with Staffing Levels

and acuity.

1-1 Care in

Labour 100% 96.35% 95.8%PCH 96.8%

HH 95.9%

Improvement plan in place to achieve 100% compliance. Escalation Policy in place

where midwives are redeployed across the service to promote 1-1 care in labour and

safety. SPC variation showing cause for concern. Improvement Plan is in place with

trajectory of March 2022 for consistent achievement. Uploaded onto maternity risk

register.

ITU admissions 0 1 0.33PCH 1

HH 0

PCH case. COVID positive, admitted to ITU prior to delivery. Decision made to deliver

baby. Transferred back to ITU post delivery.

IndicatorDate

rangeTarget

Current

Aug 21

Average

(rolling

quarter)

Variance Special causes Comments on red RAG rating/variance concern

Maternal Deaths 0 1 0.33PCH: 1

HH: 0

PCH case. Maternal death at 3 weeks postpartum. Significant PE.

Declared SI and reported to HSIB for investigation.

ATAIN reviewed

within 30 days95% 71.5% 90.5%

PCH: 100%

HH 43%NEW SPC

PCH 100%. HH risk midwife absence and unit acuity affected ability to

complete reviews.

Pre term deliveries

(<37/40) 6% 9.85% 9.45%PCH:10.5%

HH: 9.2%

SPC shows no cause for concern. At HH 1/3 of premature deliveries were

twins.

PCH no obvious cause for increase. Possible link with COVID 19 and

premature delivery. IOL and twin rate in prem deliveries low at PCH.

Skin to skin 82% 74.5% 74.8%

PCH: 71.6%

HH: 77.4%NEW SPC

Current recruitment into capacity within Infant feeding team.

Awaiting appointment in risk team to undertake observations in theatre.

Intention to

breastfeed and did 95% 85% 84.6%PCH: 82.9%

HH: 87%NEW SPC

Risk identified. Depleting members of BF team and support workers may

have contributed to this. Has been uploaded onto risk register as a risk of

not maintain bay friendly accreditation.

Exception Reporting continued

COVID 19 - Mothers

• ED and Maternity Services hardest hit by Wave 3 due to the

uptake of vaccine in pregnancy and roll out of the vaccine

among younger age groups combined with relaxing of social

distancing measures

• By the end of August approx. 62,000 pregnant women in

England has received at least one dose of the vaccine which

means that hundreds of thousands of pregnant women remain

unvaccinated

• NWAFT seeing increasing number of COIVD Positive women

in August

• Increased information regarding COVID Vaccination provided

on line and on Facebook Live event

• List of mobile vaccination drop in services communicated to

midwives

Midwifery Staffing

• Birthrate Plus acuity APP utilised in all Operational Safety Huddles

• Demonstrates that activity exceeded staffing hence lengthy closures and diverts from PCH to HH or external.

• Management Actions included suspension of Home Birth Service, Review of elective work, redeploying nurses

from across NWAFT to assist in recovery and on PN ward, redeployment of midwives from community, specialist

midwives and senior midwives to work clinically. Request accepted to extend submission on CoC Plan, Pastoral

support workshops, recruitment of a PMA, Debriefing sessions

11

12

Midwifery Staffing – HH Labour Ward

• 27 census points where activity exceed midwifery hours

Midwifery Staffing

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Update on Recruitment

• Progressing International Recruitment for 6 midwives who directly applied to the Trust

• Interviews established for 5 different posts

• 3.22 wte Nursery Nurses, 16.7 wte external midwives all grades offered and accepted posts and 2.6 band 6

midwives commenced with the organisation

• Application made for 10 overseas midwives as part of the regional collaborative international midwifery recruitment

bid for national funding

• Application to national funding made for £100,000 to focus on retention of midwives and awaiting outcome of

application

• About to advertise for six registered nurses to complete the midwifery conversion course

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Workforce

15

Staff Feedback GMC Trainee Survey 2021 Results (Obstetrics)

16

Staff Feedback GMC Trainee Survey 2021

Results (Obstetrics)

• Proportion of speciality trainees in Obstetrics and Gynaecology responding with “excellent or good” on how would

they would rate the quality of clinical supervision our of hours

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• The Trust Board is required to review the full SI Report as per recommendations outlined in the Ockenden Report.

Consideration and decision is required from the Trust Board member of how this can be fulfilled

Maternity SI’s and HSIB Cases Declared in August 2021

STEIS Number Site/ Division / Ward STEIS SI Category STEIS SI Sub-categories

2021/16153PCH/ Maternity / Delivery

Suite

Unexpected / potentially avoidable

injury causing serious harm

Adverse media coverage or public concern about the organisation or the wider NHS

meeting SI criteria

2021/16280

PCH/ Maternity / Delivery

Suite


injury causing serious harmMaternity/Obstetric incident meeting SI Criteria: mother and baby

2021/16829

PCH/EMED & Maternity / ED

& Delivery Suite

HSIB – reportable


deathTreatment delay meeting SI criteria

18

Maternity SI’s and HSIB On-going Cases

19

Hinchingbrooke

Peterborough

Maternity Incidents Moderate and above referred to Weekly Rapid Review

Maternity Incidents Moderate and above referred to Weekly Rapid Review

Datix Code Information Severity OutcomeW210258 C66 – Pt ID Error NIPE performed on inpatient baby on

transitional care.The wrong patient’s notes were completed on NIPE smart system resulting in baby going home with other babies notes.

3 Both babies have completed NIPE screening within the timeframe and the outcome correctly recorded.IG breach.No harm causedRemain level 3

W212312 G17D – PPH > 1500 mls PPH of 1.5L in total following shoulder dystocia 3 Downgraded to level 1

W212644 G23 – ¾ degree perineal tear

3rd degree tear following NVD 3 Downgraded to level 1

W211084 G17D – PPH > 1500 mls 4th caesarean, extensive adhesions. PPH 1.6L 3 Downgraded to Level 1

W207452 G39A – Unexpected admission to NICU/SCBU

Admitted to NICU for transfusion on SBR chart 3 Reviewed at ATAINStatements and process review due to break down in processNo long term harmInternal RCA and look at action planDowngraded to level 2

W210532 G7 Maternal Death Maternal death 2/52 postnatal, known PENot notified via ED therefore maternal death policy not yet activated

5 Reported to HSIB72hr report and take to SCIG – declared SIIssues with medical management identified. Local learning identified

W210348 G17D – PPH > 1500 mls Blood loss of 3.9l. Fully dilated. Declined vaginal delivery. CS at fully. Extensions to uterus. Goof evidence of Montgomery principles

3 72hr report and take to SCIG – not declared SI Maintained as 3. Consultant presence should have been sought prior in anticipation of difficult instrumental.

W211992 G31A – Antenatal and newborn screening programme incidents.

Unbooked. Untreated syphilis. Results not fast racked. Suspected syphilis in baby and delayed treatment.

3 Taken to SCIG – not declared SIResults identified no syphilisDowngraded to 0.

Peterborough

21

Maternity Incentive Scheme Year 4 (CNST) Update

• Year 4 published August 2021. NHS Resolution are due to

review some of the milestones given the feedback from

maternity services across the England

• Baseline Position is shown in the graph

• Main challenge will be achieving 90% training compliance

• Working groups established. Meeting with consultants

arranged to discuss the RCOG guidance on the recently

published Role of the Obstetric Consultant

Safety Action No.

Safety Action Current RAG Position

Comment

SA1 Use of PMRT On Track Continuation of processes and improvement

SA2 Maternity Services Data Set On Track Continuation of processes and improvement

SA3 Avoiding Term Admissions to NICU On Track Continuation of processes and improvement

SA4 Maternity Staffing On Track Continuation of processes and improvement

SA5 Midwifery Staffing At risk Continuation of processes and improvement a challenge re 1-1 and supernumerary status given staffing position. Plan to be strengthened

SA6 Saving Babies Lives At Risk Stretched targets and longer compliance timeframe

SA7 User Feedback On Track Continuation of processes

SA8 Multi-professional Training At Significant Risk

Risk relates to 90% target for training, PD Capacity due to vacancies

SA9 Maternity Safety Champions On Track Continuation of processes

SA10 Referral to HSIB and Early Notification Scheme

On Track Continuation of processes

22

Ockenden Update

• Feedback on submission now expected October

2021

• K2 Digital Notes upgraded to include Ockenden

recommendations

• 4th Cycle of audit of complex pregnancy and risk

assessment completed with improving position

for named consultant but not yet 100% compliant

• Audit of MDT Safety Huddles audited with

requirement to improve consultant obstetrician

attendance in the evening, Neonatal presence at

Delivery and continued improvement of

anaesthetists being present at PCH and HH

Maternity unit PCH HH NWAFT

Freedom to speak up /

Whistle blowing themes

Staffing

Supernumerary status

Staffing in Triage

Themes from Datix (to

include top 5 reported

incidents/ frequently

occurring )

• Inadequate levels

• 3 /4 th degree tear

• Unexpected admissions to NICU/SCBU

• PPH >1500mls

• Failure to adequately monitor

• Inadequate levels

• PPH >=1500mls

• Unexpected admissions to

NICU/SCBU

• Misfiled notes

• Protocol not followed

• Inadequate levels – staffing related

• Unexpected admission to NICU

• 3 /4 th degree tear

• Failure to adequately monitor – USS capacity – on risk register

Themes from Maternity

Serious Incidents (Sis)

Not listening to the women/taking concerns seriously

Communication/escalation and lack of SBAR

ED pathway requires review

CTG interpretation

Themes arising from

Perinatal Mortality

Review Tool

Smoking in pregnancy

Small for gestational dates

Reduced fetal movements

Themes / main areas

from complaints

Communication

Home Birth Service

Not being Listened to

Attitudes

Listening to women

(sources, engagement /

activities undertaken)

Online survey for Continuity of carer

COVID 19 vaccination awareness

Breastfeeding promotion

Video regarding home birth service

Facebook Live Event

Birth Afterthoughts Appointments

Evidence of co-

production

Charlotte’s story

Birth afterthoughts review ongoing

Listening to staff (eg

activities undertaken,

surveys and actions

taken as a result)

Pastoral Support Sessions

Band 7 extraordinary meeting

Podcast by HOM

Weekly HOM/DOM session

Embedding learning

(changes made as a

result of incidents /

activities / shared

learning/ national

reports)

• Documentation issues - lack of detail and discussion

of risk/benefit

• Escalation issues to senior obstetric team

• Lack holistic/helicopter view

• PET/FGR guideline being reviewed

• Introduction of maternity LocSSIP for delivery rooms

• Increased TCBR in the community

• Provision of local jaundice guideline

Low threshold for performing TCBR

on babies with darker skin tones and

families that raise concern of

suspected jaundice

• Guideline review around vaping in

pregnancy

• PET learning – ensuring women are aware of symptoms

• Fetal monitoring –using the correct tool

• Need for clear communication with women – to listen/empower them to

raise concerns

• WHO/locSSIP’s are fully completed

• Training need around K2

• Reinstate CO monitoring

• Encourage professional curiosity –don’t assume

Learning

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Multi-professional Training (MPT) Compliance –August 2021

• Operational pressures have led to cancellation of study in line with the maternity escalation policy

• Meeting arranged with MDT education team to plan training and update TNA

• Training compliance among medical colleagues require further focus

Course Target Midwives Bank Midwives

Obstetric (Consultants)

Obstetric (REG)

Obstetric (SHO)

Obstetric LOCUM

Support Staff

Recovery Nurses

Anaesthetist Neonatal Drs

Neonatal Nurses

Total Obstetric Emergency (MDT and single professional)

90% 97% 94% 90% 79% 19% N/A 73% 100% 45% N/A N/A

MDT Obstetric Emergency (Introduced in January 2021)

90% 54% 56% 90% 79% 19% 100% 45% 67% 45% N/A N/A

Neonatal Resuc Training

90% 97% 100% 65% - NA so stopped 100% N/A 100% N/A Need to be NLS

98%

Neonatal Life Support Qualified

90% TBC N/A N/A N/A N/A N/A N/A N/A N/A 90% 90%

Fetal Monitoring Study Day

90% 83% 30% 40% 40% N/A N/A N/A N/A N/A

Fetal Monitoring – Annual Competency Test

90% 69% 48% 48% 48%

Gap Grow Training 90% 59% 39%

Maternity Report

Documents