Amos Maternity Investigation

2. DHSC, NHSE, Integrated Care Boards (ICBs) and NHS trusts must take action to listen to the voices of women, birthing people and families within 12 months. Listening to the voices of women, birthing people and families using maternity and neonatal services is vital to safety and improving outcomes. In addition to continuing to progress existing initiatives underway in support of this aim, including the rollout of the Patient Reported Experience Measure (PREM) tool for maternity and neonatal services, we recommend the following actions: • Treat listening to, hearing and acting on the voices of women and birthing people as a critical safety issue. This means that at trust level, data on listening to women must be captured as safety intelligence, reviewed through patient safety governance, escalated to board level where patterns emerge and linked to measurable improvement action. It must also be considered by regulators as part of their assessment of service safety. • Enhance the existing maternity pathway by ensuring that: – Continuity of carer is provided for all scheduled antenatal and postnatal care – Every health professional moves away from a fixed risk categorisation for women and birthing people at the start of pregnancy as ‘high risk’ or ‘low risk’ with risk being dynamically assessed at every scheduled appointment – A postnatal debrief discussion is offered to every woman and birthing person, by a midwife or appropriately trained clinician. • Enhance the existing neonatal pathway by ensuring that: – Transitional care and neonatal community care services are available to all families in order to keep mothers and babies together and avoid unnecessary admission to all types of neonatal unit – A standardised neonatal palliative care service model must be in place for all families when needed, ensuring that they are heard, informed and that palliative care is planned with families. • Embed trauma-informed principles across maternity and neonatal care as routine practice. This includes expanding provision of trauma-informed psychological support to families as a matter of routine practice after experiencing harm in care. Trauma-informed psychological support must be clearly demarcated as distinct from bereavement support. • Commission and deliver antenatal education that reflects the realities of pregnancy and birth today, including induction of labour, caesarean births and pain relief. To facilitate inclusivity, proactive contact must be made with women and families, particularly those from more disadvantaged backgrounds. This education must be redesigned in partnership with women, birthing people, families and staff.

3. DHSC, NHSE and CQC must drive improvement, within 12 months, of the quality, transparency, oversight and accountability of investigations and ensure learning is captured and acted upon when things go wrong. When death or harm occurs families should be offered a full explanation of what happened. There is an imbalance of power between trusts and families and the resources available to them, which can prevent families from receiving the answers they deserve when things go wrong. Greater clarity regarding how all investigation pathways should be delivered is required, along with an improvement in investigation expertise. To address this, we recommend that: • If, after all trust reviews and investigations have been completed, families are not satisfied with the answers they have received, families must have the right to request that a trust commissions an independent investigation of the circumstances of their individual case. • The pathways and processes for investigating when things go wrong should be clearly communicated to families, including providing details about: how families will be involved and updated; how investigations will be led; what external scrutiny is required; and what timeline families can expect. • All current investigation types must include independent challenge at every stage, which must be explicitly stated in policy and operational documents. • A national specialist training programme must be designed and rolled out to equip all investigation staff with the skills and protected time needed to carry out reviews and investigations to a consistently high standard and communicate compassionately with families and staff. • Learning from investigations and reviews must be systematically shared at national and regional level with robust quality assurance, and oversight of the implementation of all recommendations arising from investigations must be strengthened at local, regional and national level. • The health and social care regulator, CQC, must include the assessment of the quality of investigations in their regulatory framework.

4. DHSC/NHSE must design a Modern Service Framework for maternity and neonatal services within 12 months and begin rollout within 18 months. The maternity and neonatal service model needs to be redesigned to consistently achieve high-quality maternal and neonatal care: improving outcomes, meeting core safety standards and ensuring excellent family experience, which meets the demands and requirements of a modern service. We recommend: • The Modern Service Framework takes a safety systems approach to design a set of national standards which will deliver responsive, safe and improved services and outcomes across the whole care pathway – from preconception care to postnatal and neonatal care, including investigations and reviews when things go wrong. The Modern Service Framework must shift the maternity service to a more agile design which can respond to the demands of both planned and unplanned (urgent and emergency) care. This must be developed in collaboration with women, families, staff and experts. • Maternity triage must be formally designated as a safety-critical clinical environment, with binding national standards rather than guidance. • A set of unified national standards for clinical, professional and operational guidance for maternity and neonatal services must be produced. This must be developed in partnership with national professional organisations, including the National Institute for Health and Care Excellence (NICE), Royal Colleges and professional bodies. • A redesigned workforce model must be developed and implemented, underpinned by a new multidisciplinary workforce tool for maternity and neonatal services. This must include: – Specific consideration of the need for obstetric consultants and anaesthetists to be available on a delivery unit for timely critical senior decision making and intervention 24 hours a day, seven days a week and a formal review of rota models. In the interim, trusts must mandate adherence to current Royal College of Obstetricians and Gynaecologists (RCOG) guidance on consultant and senior presence in and out of hours. – Balancing the skill mix of midwives across the 24-hour period, ensuring care is not compromised when specialist midwives are unavailable and that senior midwifery staff are supported to remain visible and clinically active alongside their managerial responsibilities. This must take into account the need to support midwives with career progression. – Developing the workforce model in collaboration with midwives, obstetricians, neonatologists, anaesthetists, Directors of Public Health and others. • DHSC/NHSE must review the optimal size and configuration of maternity and neonatal units to deliver reliable safe care. Neonatal Operational Delivery Networks (ODNs) should match geographically with NHS regions. This should include consideration of whether neonatal and maternity services should be commissioned together. • DHSC/NHSE must ensure that existing research funding is targeted at the issues where an improved evidence base will support delivery of the new Modern Service Framework. This must include: – An independent study of the accuracy of different growth charts available for measuring fetal growth and their ability to reduce adverse outcome. – Ensuring there is a sound evidence base when implementing new policies and guidance. This should include stopping mandatory initiatives which lack evidence and feasibility.

5. DHSC, NHSE, ICBs, NHS trusts, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) must treat racism, discrimination and inequality as a critical maternity safety issue – within 12 months, with work starting immediately. Racism and discrimination, whether overt or structural, whether experienced by those receiving care or by the staff providing it, are not peripheral concerns to be addressed through occasional training or local initiatives. As Lord Darzi said: “The impact of the deterioration in access and the challenges around quality of care have not been felt equally. As we have seen, there are important disparities in almost all aspects of care. The ‘inverse care law’ seems to apply: that those in greatest need tend to have the poorest access to care”. In addition to accelerating delivery of existing work underway in this area, led by the NHS Race and Health Observatory, we recommend that: • Racism and discrimination must be treated as a critical safety issue requiring urgent intervention. This means that at trust level, where inequalities in access, experience, safety or outcomes are identified, data must be captured as safety intelligence, reviewed through patient safety governance, escalated to board level where patterns emerge and linked to measurable improvement action. It must also be considered by regulators as part of their assessment of service safety. • An independent evaluation of anti-racism training currently being delivered across maternity and neonatal teams is commissioned by DHSC/NHSE, assessing quality, consistency, and measurable impact on staff behaviour and patient experience. The findings should be used to establish a national minimum standard for mandatory training. • Trusts must take immediate action to collect, analyse and act on the most granular data their systems allow, using this to identify inequities in access, experience, safety and outcomes, and to target service improvement without stereotyping or attributing risk to communities themselves. • DHSC should explore reviewing and reforming the data categories used across health datasets, to ensure they reflect the true diversity of the women and babies being served. • The GMC and NMC should keep referrals from trusts under review to identify potential racial bias and discrimination. They must alert relevant trusts to any concerns identified, which must be investigated.

6. DHSC/NHSE must clarify existing system governance, oversight and accountability structures and improve the effectiveness of regulatory oversight within nine months. To enable the success of the new Modern Service Framework, a streamlined, national oversight and leadership model must be put in place so that clear lines of governance, accountability and escalation are in place at all levels of the system. Steps must be taken immediately to improve the regulatory oversight provided by CQC and other relevant bodies. To do this, we recommend that DHSC/NHSE must: • Lead work to ensure that the organisations responsible for maternity and neonatal services work together to clarify responsibilities, remove duplication and improve effectiveness. This includes, as a minimum, CQC and professional regulators such as the GMC and NMC, alongside professional bodies including the Royal Colleges. • Work with CQC to improve its effectiveness immediately and start work to put in place a specialist regulatory unit, with a sufficiently sensitive methodology, to provide regulatory assessment for maternity and neonatal services. This unit must include clinicians from a range of professional backgrounds to ensure the most recent clinical perspectives are fully integrated into the regulatory function. The methodology must put the views of women and families at its centre and be kept under regular review.

7. DHSC, NHSE, ICBs and NHS trusts must work with colleges, universities, postgraduate educators and others to improve culture and teamworking, and strengthen leadership at all levels of the system and across professions within 12 months. Strong, supportive, visible and approachable leadership and teamworking across professions from teams/ward, to board, to DHSC is essential for delivery of objectives, staff morale and confidence and creating the right culture and leadership structures to enable staff to provide safe and compassionate care. Poor behaviour (including bullying, racism and discrimination) by leaders and senior clinicians has an impact on safety and must be tackled by trust leaders. We recommend that: • Developing a positive culture which prevents and tackles poor and unacceptable behaviour should be treated as a critical safety issue. This requires good teamworking with common objectives. Any barriers must be identified and measures taken to address poor and unacceptable behaviour, including group training, team development, staff welfare and psychological support. Reports of poor and unacceptable behaviour must be captured as safety intelligence, reviewed through patient safety governance, escalated to board level where patterns emerge and linked to measurable improvement action. It must also be considered by regulators as part of their assessment of service safety. • A review of obstetric clinical director and senior medical posts must be undertaken by DHSC/NHSE, including how these posts can be established as substantive posts, which become a desirable subspecialisation in clinical management and support progression to senior obstetric posts. These roles should be given sufficient time, training and administrative support. • All trusts must ensure there is parity between midwifery, obstetric and neonatal leads at every reporting level, including a senior obstetric clinical lead working alongside the Director of Midwifery in each provider. Matched clinical obstetric and midwifery consultant lead roles must be in place to support joint care planning for services and women clinically. These posts must have a primary focus on safe, evidence-based care, separate from operational management of the units. At board level, the Chief Medical Officer for the trust must consistently engage on maternity and neonatal care issues alongside the Chief Nurse. • A fundamental review of undergraduate and postgraduate education must be undertaken to include development of interconnected curricula and opportunities for shared learning and ongoing multi professional training for all professional groups (midwifery, neonatal and medical) to support joined up care planning. • Education and training for all clinicians — at every stage of their career — must place trauma-informed care, bereavement care, compassionate care, communication, teamworking and response to adverse events at its core.

8. DHSC/NHSE must deliver estates and digital systems that are fit for modern maternity and neonatal care with 12-month, five-year and 10-year investment commitments and implementation deadlines. The physical environments in which women give birth and babies receive their earliest care must be safe, protect privacy and be in acceptable condition. Estates and digital infrastructure are the foundations of safe care, and they have been eroded by sustained underinvestment. We recommend: • Clear, enforceable standards for estates must be set out in the Modern Service Framework. Health Building Notes (HBNs) 09-02 and 09-03 for Maternity Care and Neonatal Facilities, published in 2013, are no longer fit for purpose and must be comprehensively revised within 12 months. Updated standards must reflect the operational realities of modern service delivery, mandating safety for women, families and staff at all times. The government must set out 12-month, five-year and 10-year investment plans for long-term capital investment. These should deliver the revised standards for new and existing estates, including tackling the immediate maintenance and refurbishment backlog. The 12-month, five-year, and 10-year investment commitments must be published and subject to parliamentary oversight. • A clear national implementation timeline must be set for the rollout of interoperable digital maternity and neonatal systems across all providers, including defining, mandating and collecting clear national datasets, to ensure that every woman and baby has one single, digital record that follows them wherever they receive care. This should include consolidation of one unified national data set for maternity and neonatal care, which also includes public health and epidemiological data, made available in a simple format in order to identify trends and monitor performance. Digital investment must also extend to emerging technologies that support the quality and safety of clinical interactions.