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Select Committee · Health and Social Care Committee

Safety of maternity services in England

Status: Closed Opened: 24 Jul 2020 Closed: 26 Oct 2021 23 recommendations 8 conclusions 1 report

This inquiry will examine evidence relating to ongoing safety concerns with maternity services. It will build upon investigations that followed incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. We will also consider whether the clinical … Show more

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Reports

1 report
Title HC No. Published Items Response
Fourth Report - The safety of maternity services in England HC 19 6 Jul 2021 31 Responded

Recommendations & Conclusions

7 items
4 Recommendation Fourth Report - The safety of maternity… Accepted

We further recommend that the Department work with the Royal College of Obstetricians & Gynaecologists...

We further recommend that the Department work with the Royal College of Obstetricians & Gynaecologists and Health Education England to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric staffing over the years to come. This work should also … Read more

Government response AI summary
The government accepts this recommendation, highlighting existing collaboration with HEE and RCOG on workforce planning for obstetrics, gynaecology, and anaesthetics. They note the recent funding for an RCOG tool, to be available next year, which will help NHS Trusts calculate their obstetrician staffing needs.
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Department of Health and Social Care
8 Conclusion Fourth Report - The safety of maternity… Accepted

While it is encouraging that 93% of trusts are meeting the training objective set out...

While it is encouraging that 93% of trusts are meeting the training objective set out in the Maternity Incentive Scheme, it is disappointing that only 8% of units across the UK are meeting the very highest standards of training, as set out in the Saving Babies Lives Care Bundle. It … Read more

Government response AI summary
The government accepts the recommendation and is developing a Core Competency Framework and a national Registry of Recommendations to address training variations and ensure minimum core requirements for maternity services. They will also work with Royal Colleges and the CQC on standardising fetal monitoring training.
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Department of Health and Social Care
12 Recommendation Fourth Report - The safety of maternity… Accepted

Clinicians of all disciplines should also receive training before they are qualified in how they...

Clinicians of all disciplines should also receive training before they are qualified in how they should respond to the sorts of error that these investigations may uncover. This would include help for clinicians on accepting a degree of fallibility. Being unable to respond appropriately to mistakes is harmful to the … Read more

Government response AI summary
The government accepts the recommendation, committing that maternity services will complete a Training Needs Analysis and NHSEI will work with HEE to ensure national training packages support relevant staff, aligning with the Core Competency Framework.
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Department of Health and Social Care
15 Conclusion Fourth Report - The safety of maternity… Accepted

We recognise the effort of individual organisations to collect data and insights on maternity care.

We recognise the effort of individual organisations to collect data and insights on maternity care. The potential value of this information to drive improvements in maternity care is clear. However, at present these insights are not being fully utilised. Read more

Government response AI summary
The Government accepts in part, committing to commission a single notification portal (LFPSE) in 2021/22 to streamline data collection and sharing, improve MSDS data, and highlights the existing Maternity Services Dashboard to enhance data utilisation.
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Department of Health and Social Care
22 Recommendation Fourth Report - The safety of maternity… Accepted

Finally, given their recognition of the role the professional regulators have in ending the blame...

Finally, given their recognition of the role the professional regulators have in ending the blame culture, we recommend that the General Medical Council and the Nursing and Midwifery Council review what changes are required to their remits or working practices to reduce the fear clinicians have of their regulators and … Read more

Government response AI summary
The government welcomes the recommendation, noting that DHSC is working with regulators and highlighting existing work by the GMC and NMC, such as new guidance, outreach sessions, and commissioned research, which are already addressing the blame culture and supporting a just culture within healthcare.
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Department of Health and Social Care
24 Recommendation Fourth Report - The safety of maternity… Accepted

Having the right skill set, as noted above, is crucial for the successful implementation of...

Having the right skill set, as noted above, is crucial for the successful implementation of continuity of carer. We therefore recommend that those involved in delivering this model have received appropriate training and that all professionals are competent and trained in all areas that they work in, particularly in relation … Read more

Government response AI summary
The government accepts this recommendation, committing to requiring all maternity services to complete a Training Needs Analysis with provided guidance. NHSEI will also work with HEE to ensure national training for 2021/22 supports skill updates for Continuity of Carer teams and care for women from …
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Department of Health and Social Care
31 Recommendation Fourth Report - The safety of maternity… Accepted

It is deeply concerning that maternity units appear to have been penalised for high Caesarean...

It is deeply concerning that maternity units appear to have been penalised for high Caesarean Section rates. We recommend an immediate end to the use of total Caesarean Section percentages as a metric for maternity services, and that this is The safety of maternity services in England 57 replaced by … Read more

Government response AI summary
The government accepts this recommendation, agreeing that Caesarean Section rates should not be used for performance management and supports the use of Robson criteria. NHSEI will issue further communication advising against total Caesarean rates and encouraging the intelligent use of Robson group data for quality …
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Department of Health and Social Care

Oral evidence sessions

5 sessions
Date Witnesses
2 Feb 2021 Dr Matthew Jolly · NHS England, Ms Nadine Dorries · Department of Health and Social Care, Professor Jacqueline Dunkley-Bent · NHS England and NHS Improvement, Sarah-Jane Marsh · NHS England, William Vineall · Department of Health and Social Care View ↗
19 Jan 2021 Andrea Sutcliffe · Nursing and Midwifery Council, Charlie Massey · General Medical Council, Doctor Daghni Rajasingam · The Shelford Group, Gill Adgie · Royal College of Midwives, Jo Mounfield · Royal College of Obstetricians and Gynaecologists, Niamh Maguire · Sussex Local Maternity System, Professor James Walker · Healthcare Safety Investigation Branch, Sara Ledger · Baby Lifeline View ↗
15 Dec 2020 Clotilde Rebecca Abe · FiveXMore Campaign, Donna Ockenden · Independent review into Maternity Services at The Shrewsbury And Telford Hospitals - Maternity Admin, Dr Edward Morris · The Royal College of Obstetricians and Gynaecologists (RCOG), Gill Walton · Royal College of Midwives, Professor Gordon Smith · University of Cambridge, Professor Jenny Kurinczuk · University of Oxford, Professor Marian Knight · National Perinatal Epidemiology Unit, Tinuke Awe · Five x More View ↗
3 Nov 2020 Darren Smith, bereaved parent, Dr Jenny Vaughan · Doctors' Association UK, Dr Pelle Gustafson · Swedish Patient Insurer, Dr Sonia MacLeod, Helen Vernon · NHS Resolution, James Titcombe, bereaved parent View ↗
29 Sep 2020 Dr Bill Kirkup · Morecambe Bay maternity investigation and East Kent maternity investigation, Dr Matthew Jolly · NHS England, Miss Michelle Hemmington · Campaign for Safer Births, Professor Jacqueline Dunkley Bent · NHS England and NHS Improvement, Professor Ted Baker · Care Quality Commission View ↗

Who gave evidence

31 witnesses
WitnessOrganisationSessions
Dr Matthew Jolly · National Clinical Director for the Maternity Revi… NHS England 2
Andrea Sutcliffe · Chief Executive Nursing and Midwifery Council 1
Charlie Massey · Chief Executive and Registrar General Medical Council 1
Clotilde Rebecca Abe · Co-founder FiveXMore Campaign 1
Darren Smith, bereaved parent — 1
Doctor Daghni Rajasingam · Consultant Obstetrician The Shelford Group 1
Donna Ockenden · Chair Independent review into Maternity Services at The Shrewsbury And Telford Hospitals - Maternity Admin 1
Dr Bill Kirkup · Chairman Morecambe Bay maternity investigation and East Kent maternity investigation 1
Dr Edward Morris · President The Royal College of Obstetricians and Gynaecologists (RCOG) 1
Dr Jenny Vaughan · Consultant Neurologist, Learn Not Blame, Law and … Doctors' Association UK 1
Dr Pelle Gustafson · CMO Swedish Patient Insurer 1
Dr Sonia MacLeod — 1
Gill Adgie · Regional Head Royal College of Midwives 1
Gill Walton · Chief Executive Royal College of Midwives 1
Helen Vernon · Chief Executive NHS Resolution 1
James Titcombe, bereaved parent — 1
Jo Mounfield · Vice President for Workforce and Professionalism Royal College of Obstetricians and Gynaecologists 1
Miss Michelle Hemmington · Co-founder Campaign for Safer Births 1
Ms Nadine Dorries · Minister of State for Mental Health, Suicide Prev… Department of Health and Social Care 1
Niamh Maguire · Obstetric Clinical Lead Sussex Local Maternity System 1
Professor Gordon Smith · Professor of Obstetrics and Gynaecology University of Cambridge 1
Professor Jacqueline Dunkley Bent · Chief Midwifery Office NHS England and NHS Improvement 1
Professor Jacqueline Dunkley-Bent · Chief Midwifery Officer NHS England and NHS Improvement 1
Professor James Walker · Clinical Director of Maternity Investigation Prog… Healthcare Safety Investigation Branch 1
Professor Jenny Kurinczuk · Professor of Perinatal Epidemiology & Director, N… University of Oxford 1
Professor Marian Knight · Director National Perinatal Epidemiology Unit 1
Professor Ted Baker · Chief Inspector of Hospitals Care Quality Commission 1
Sara Ledger · Head of Research Baby Lifeline 1
Sarah-Jane Marsh · National Priority Programme Director for Urgent a… NHS England 1
Tinuke Awe · Co-founder Five x More 1
William Vineall · Director of NHS Quality, Safety and Investigations Department of Health and Social Care 1

Correspondence

6 letters
DateDirectionTitle
7 Jul 2021 — Correction to written evidence submitted by NHS Resolution to the Safety of mat…
6 Jul 2021 — Transcript of maternity services roundtable with clinicians on 7 January 2021
15 Jun 2021 To cttee Letter from NHS Providers on maternity workforce expansion
25 May 2021 To cttee Letter from the Royal College of Midwives on the Committee's inquiry into Safet…
27 Apr 2021 To cttee Letter from the Minister of State for Patient Safety, Suicide Prevention and Me…
6 Jan 2021 To cttee Letter from Dr Jenny Vaughan following up from a question asked during the Saft…