Recommendation 13

HM Government Not Addressed

51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health and Care Bill contains provisions which allow for NHS England or any other public body to carry out maternity investigations in the future. 53. The Government will decide which option is the most appropriate in due course and seek the views of the NHS, families and other interested parties. 54. HSIB recognises that timely production of its investigation reports is essential to support trusts and their staff with learning, to ensure that families are given the clarity they need about what happened during their care, and what actions can be taken by the Trust to reduce the risk of recurrence. In the last 12 months, HSIB has made changes to improve the timeliness of its reports, strengthened its collaboration with Trusts and multidisciplinary engagement with perinatal teams to ensure that learning is spread as widely as possible from its investigations. 55. Substantial adjustments to a range of processes along the investigation pathway has also enabled HSIB to clear the backlog of investigations that extended beyond six months, and to ensure that the average turnaround time for sharing the draft investigation report is four months and the final investigation report with Trusts is now completed within six months in over 90 percent of cases. 56. There is an established process in place to have open discussions around any concerns that are identified during the investigation. This enables immediate safety actions to be taken by the Trust. Where cases are exceeding the six-month timescale, this will generally be due to additional time needed by the family or the Trust to review the report. 57. HSIB investigations can sometimes be delayed by factors beyond HSIB’s control, such as access to medical records or access to specialist medical advice. In addition, parallel investigations being conducted by professional regulatory bodies, coroners or the police, can require HSIB to pause an investigation until those processes have been completed. However, HSIB recognises that the proportion of investigations which are affected by these processes is very small and the average duration of an investigation continues to improve. 58. HSIB has a formalised and standardised process for factual accuracy checking with families and Trusts on draft maternity investigation reports. This process requires Trusts to formally advise whether they have accepted HSIB’s recommendations. HSIB asks Trusts to ensure that any staff involved in the HSIB investigation are given the opportunity to contribute to the factual accuracy review. HSIB also ensures that the Trust board’s Maternity Safety Champion is informed about recommendations that the Trust has not accepted. 59. All families and Trusts are offered the opportunity to hold a tripartite meeting with HSIB at the conclusion of an investigation. Doing this enables HSIB to discuss the findings and allows the Trust an opportunity to share their planned actions with the family. This also helps to provides a clear point of conclusion for the HSIB investigation and facilitates a more constructive relationship between the trust and the family going forward. 60. HSIB is continuously improving the accessibility of local learning from their investigations to support improvement. They hold Quarterly Review Meetings (QRMs) with all Trusts which are open to multidisciplinary attendance and are also attended by senior trust leaders. The QRMs provide an opportunity to share national, regional and local Trust data on numbers of investigations, criteria breakdown and frequently recurring themes at each level. HSIB is developing mechanisms for more effective engagement with doctors in training and midwives, and they encourage Trusts to facilitate trainees’ and midwives’ attendance and participation at the Trusts’ QRMs. HSIB also attends, when invited, Trust perinatal and governance meetings and meetings with wider clinical teams to share their investigation findings. They continue to work closely with the Royal Colleges and HEE to build awareness of HSIB through healthcare training. They have also created a staff engagement video which explains the importance of staff involvement in HSIB investigations, which has been shared with all Trusts and is also publicly available. 61. HSIB’s collaborative approach also involves using Trust feedback to shape the programme. HSIB has recently commenced a survey of all Trusts participating in the maternity programme, building on learning and improvements that they obtained from conducting the survey in early 2020, the results of which were shared with Trusts. This has helped to build the confidence of Trusts and staff that HSIB is collaborative and willing to learn from their experience to continuously improve the programme. 62. HSIB is also developing a learning and development