University Hospitals Sussex NHS Foundation Trust
NHS / Health Body
Action Taken
The trust shared messages on record keeping, audited maternity records, and took individual action with involved midwives. (AI summary)
View full response
Dear Ms Andrews
Response to the Regulation 28: Report to Prevent Future Deaths following the Inquest touching upon the death of Alissa Norton.
This letter is to outline the actions taken by University Hospitals Sussex NHS Foundation Trust following the receipt of the Regulation 28 report dated 26 February 2024.
The maternity service and wider organisation have taken the concerns raised by the Coroner extremely seriously.
The following actions have been completed or are in progress:
1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.
2. Sharing of the message outlined in point 1 at the monthly Trust wide Nursing, Midwifery and Allied Health Professional Quality and Safety meeting on 2nd April 2024, Quality Governance Steering Group on 18th March 2024, Patient and Quality Committee on 26th March 2024, and Trust Board on 28th March 2024.
3. Sharing of the outlined in point 1 at the joint obstetric consultant meeting on 1st March 2024.
4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.
5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.
6. Appropriate individual action has been taken with the midwives involved in this case and is ongoing.
Response to the Regulation 28: Report to Prevent Future Deaths following the Inquest touching upon the death of Alissa Norton.
This letter is to outline the actions taken by University Hospitals Sussex NHS Foundation Trust following the receipt of the Regulation 28 report dated 26 February 2024.
The maternity service and wider organisation have taken the concerns raised by the Coroner extremely seriously.
The following actions have been completed or are in progress:
1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.
2. Sharing of the message outlined in point 1 at the monthly Trust wide Nursing, Midwifery and Allied Health Professional Quality and Safety meeting on 2nd April 2024, Quality Governance Steering Group on 18th March 2024, Patient and Quality Committee on 26th March 2024, and Trust Board on 28th March 2024.
3. Sharing of the outlined in point 1 at the joint obstetric consultant meeting on 1st March 2024.
4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.
5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.
6. Appropriate individual action has been taken with the midwives involved in this case and is ongoing.