Maternity learning review publication

In a commitment to learning and transparency, University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) has today (22 February) published the report findings from an independent maternity learning review it requested last year.

In the autumn the Trust - taking lessons from national reports that have highlighted the need for openness to learning from incidents - asked the NHS Derby and Derbyshire Integrated Care Board to commission an independent review into seven maternity incidents that took place at Royal Derby Hospital between January 2021 and May 2022.

The cases over this 16-month period sadly related to three maternal deaths and four maternal collapses; all seven cases had already been individually investigated, but allowing an independent team to review them collectively was designed to give the Trust and the families involved assurance that all possible learning had been identified.

The report, conducted by the Healthcare Safety Investigations Branch (HSIB), has now been shared with the Trust.

Dr James Crampton, UHDB Executive Medical Director, said: "The seven incidents have had a longstanding impact on the families involved, so it was paramount to us to ensure we had utilised every possible opportunity for further learning and why we proactively requested this independent review.

"Although the review did not find any common themes that impacted on the outcomes for all the women involved, there has been learning for us an organisation which we have taken very seriously, and the recommendations are invaluable in helping us further improve safety and the experience of women under our care.

"We have already addressed the report's immediate recommendations, including refining our existing major haemorrhage guidance and enhancing our emergency bleep process, and have put a comprehensive plan in place to rapidly deliver all other initial actions within the next three months.

"We would like to reiterate our apologies to the seven women and families for the experiences they had and thank them for their strength in sharing their feedback, which we will commit to using to improve the experience and care we provide to others."

Below you can read more about the review findings, what the Trust has done and will do in response, and download a copy of the full report.

Review findings

The review found that there were no identified common themes that directly impacted on all outcomes for the seven women involved.

However the review found that there were opportunities to:

  • Optimise process elements of the management of a massive obstetric haemorrhage (MOH).
  • Better involve families in learning from incidents and in decisions about their care.
  • Implement learning from former and current incidents more thoroughly and responsively.
  • Conduct initial incident reviews more quickly.
  • Improve the working relationships between some disciplines in the department, and address some reports of incivility from some senior team members.
  • Improve the clarity and consistency of guidance, and ensure documentation is completed more thoroughly.
  • Enhance the holistic care given to women when they are discharged.

It also highlighted some areas of good practice, finding that:

  • There was a primarily ‘kind and compassionate’ culture in maternity services, where staff were passionate about providing a high-quality service and pulled together to support one another.
  • In recent months there has been a new approach to governance.
  • There were examples of positive communication in community midwifery care, the theatre, intensive care unit (ICU) and the high dependency unit (HDU) - with feedback saying that staff were particularly “kind, calming and compassionate”.
  • Both the emergency and elective theatre environments were calm, spacious, and modern.

What we have already done, and what we will do next

We have already:

  • Made process changes to the existing emergency bleep system in the department, with the national 2222 procedure going live next week.
  • Revised our major obstetric haemorrhage guidance (which is going through governance review processes), and put more robust processes in place for monitoring compliance with the guideline.
  • Met with the Civility Saves Lives national campaign team to look at training and support we can access.
  • Begun a review of the holistic care provided to women, and are exploring opportunities to increase roles in bereavement support and the establishment of a family liaison officer.
  • Synchronised theatre clocks, and added a time-check requirement to our checklists at the beginning of a procedure.
  • Enhanced our existing-incident process to ensure completion of 72-hour reviews following a moderate or serious incident, including oversight from a weekly panel to look at initial findings and any immediate learning. And, in addition to using the national Patient Safety Incident Response Framework (PSIRF) to manage incidents, we have established a project implementation group to look at how we can reach better patient and family involvement.
  • Ordered a blood fridge for the Royal Derby Hospital site.
  • Completed a demand exercise around c-sections, with additional c-section lists to be scheduled from April to reduce reliance on Saturday lists.
  • Allocated a dedicated anaesthetist in each caesarean section list to prepare medications separately for each patient in an anaesthetic room, to remove a need for pre-filled syringes or for all medications to be 'pre-prepared' at the start of a list.
  • Outside of the review process we have also: got two new consultants joining in February and March; offered roles to 18 new midwives from overseas, who we hope to welcome soon; and appointed 'retention midwives' to work closely with staff to better support and develop them in their careers with us.

In the next three months we will have:

  • Developed a full programme of cultural improvement, including exploring the 'Workplace Behaviour Tool Kit' - a resource developed in collaboration with RCOG, Royal College of Midwives, Civility Saves Lives and Royal College of Surgeons of Edinburgh.
  • Looked to increase on-call registrar availability for obstetrics.
  • Considered ways in which we can further embed already-existing training and processes, which already dictate that in emergency cases a 'lead' should be identified to provide a 'helicopter view' of the situation.
  • Enhanced our training by including guidance on effective scribing to support better documentation.
  • Reviewed our antenatal admissions process to ensure a consultant is embedded on the antenatal / postnatal ward daily.          
  • Enhanced our process to close the feedback loop with staff on learning following incidents, including exploring dedicated quality and safety boards in the department.
  • Reviewed the governance structure to ensure current oversight - which already includes detailed and meaningful reports up to Board level - remains sufficient and is working effectively.                                
  • Implemented the Royal College of Obstetric and Gynaecologists (RCOG) escalation tool kit.

The report

Download a full copy of the independent maternity learning review report here.