Ockenden Review (Nottingham)

Listening to Women & Families — Strengthening women-centred communication and informed choice

• 1.All women must be provided with clear, consistent, and accessible information throughout pregnancy to support informed decision-making. This should include information about labour and birth, pain relief options in labour, anaesthetic care for operative delivery, and the potential benefits and risks of different interventions. Information should be available in a range of formats and languages and signpost women to trusted resources, including Labour Pains.org, to support informed choices and shared decision-making.
• 2.By 28 weeks' gestation, all women must receive a minimum standard set of information on labour and birth, including pain relief options and information about anaesthesia for operative and instrumental delivery. This must include balanced discussions about interventions such as caesarean birth and epidural analgesia, ensuring women are fully informed, supported to make choices that reflect their preferences, and able to develop realistic expectations of their care.
• 3.Introduce a mandatory 'Listen to the Woman and consider her preferences' assessment field within triage and telephone triage documentation to ensure the woman's account is heard captured and informs clinical decision-making.
• 4.All Trusts must ensure women and families are listened to, acting appropriately upon any concerns within a timely manner.
• 5.Neonatal services should implement the principles set out in the BAPM Family Integrated Care Framework for Practice to ensure parents are recognised as partners in care, actively involved in decision-making and supported to participate in the care of their baby wherever clinically possible.
• 6.Communication with parents must be a priority. Documentation should be consistent and clearly reflect meaningful parental involvement in daily decision-making.
• 7.Regular, open conversations with parents, including use of translation where required, should be embedded into routine practice.

Workforce Planning & Safe Staffing — Support a nationally agreed perinatal workforce planning methodology as a critical enabler of perinatal improvement at pace and scale

• 1.Investment should be made in the development and implementation of a robust, evidence-based workforce planning tool across perinatal services. The tool should move beyond birth rates alone to reflect population complexity, including factors such as maternal age, co-morbidities, deprivation, acuity and service configuration. a. Obstetric sonographers must be included within workforce/staffing models, to reflect the increasing complexity of cases and increasing workload. b. Workforce planning should recognise the substantial out-of-hours obstetric workload and ensure that staffing arrangements provide sufficient dedicated anaesthetic capacity, resilience, and senior support to meet the needs of women and babies safely at all times. A long-term increase in anaesthetic training numbers and consultant posts will be required to respond to the growing demand on obstetric anaesthetic services. Workforce planning must also consider the availability of appropriately skilled anaesthetic support staff (ODPs and anaesthetic nurses) in order to deliver safe and timely care. The methodology should be scalable across all maternity settings and sufficiently flexible to account for local variation in demand, whilst providing a nationally consistent framework for workforce planning, service design and investment decisions. It should also recognise the workforce capacity required for education and training, governance, quality improvement, leadership and patient safety activities, enabling a more accurate assessment of staffing requirements and helping ensure services are appropriately resourced to deliver safe, sustainable care.
• 2.Ensure staff models explicitly account for the provision of care to women presenting in early labour, including appropriate space and staffing to support assessment, monitoring, and ongoing care.
• 3.Postnatal wards must be appropriately staffed at all times. Postnatal staffing levels must be appropriate for both the activity and acuity of care required on the postnatal ward during the day and night for both mothers and babies. Newborn babies, on the postnatal ward, counted as individual patients.
• 4.When postnatal women are medically fit for 'step down' from critical care this must be to an appropriate maternity area, depending on their clinical needs. If step down directly to the postnatal ward is considered appropriate then additional support should be provided for at least the first 24 hours both to help the woman adjust to her changing circumstances, and to help her care for her newborn baby. The expectation is that the additional support will generally be 1:1 support which can be provided by a Maternity Support Worker (MSW) or Health Care Assistant (HCA).
• 5.All neonatal units must have adequate funded nursing and medical establishment and sufficient critical care equipment, including incubators, to be able to safely operate at 100% of planned capacity during peaks of activity, but must operate at an average of no more than 80% occupancy to allow for these surges of activity. Neonatal services should demonstrate compliance with BAPM Service and Quality Standards for Provision of Neonatal Care in the UK and relevant BAPM workforce standards.
• 6.Neonatal consultants must NEVER provide emergency cover to more than one hospital at the same time and, in-person attendance out of hours should always be within 30 minutes.
• 7.Immediate availability of consultants will be dependent on the experience of resident Tier 2 staff, particularly in relation to airway skills. This may require resident consultant models in some instances. (BAPM safety Alert 12.12.2024)
• 8.All neonatal units must use national neonatal audit programme (NNAP) (RCPCH 2026) outcomes and GIRFT (NHSE 2026) reviews to focus quality improvement work and drive improvements in those areas identified as negative outliers with an emphasis on close to real time quality surveillance alongside the use of audit data.
• 9.All maternity and neonatal services must ensure their resuscitation practice and guidelines fully align with Resuscitation Council UK (NLS) guidance (Fawke et al 2025). This includes prioritising emergency blood transfusion in severe acute blood loss and life-threatening severe anaemia.
• 10.National Neonatal Action a. All neonatal units must follow the recommendations in the BAPM Neonatal Airway Safety Standards and audit their compliance with these airway competency standards. b. All neonatal units must have immediate access to appropriate video laryngoscopy equipment. c. All NICUs and LNUs must collect data on their unplanned extubation rate per 100 ventilator days and consider quality improvements to reduce their rate. d. All neonatal units must follow and audit compliance with national and local infection control guidance including appropriate cot-spacing and appropriate hand hygiene measures.

Training & Multi-Professional Learning — National IEA for Labour Ward Coordinator Role

Implement a nationally recognised Labour Ward Coordinator (LWC) programme (NHS England (2023) Labour ward coordinator framework) for all Band 7 LWC midwives undertaking the LWC role.
Provide structured opportunities and support to achieve the competencies and standards outlined across the six domains of the national LWC Framework.
Introduce 360-degree feedback for all LWCs to support reflection, performance development, and understanding of the impact of behaviour on the multidisciplinary team.

Training & Multi-Professional Learning — All trusts must support Training for Midwives in the use of Speculum Examination

1. All Trusts must ensure that midwives are supported to achieve local training competencies to perform speculum examinations for women at any gestation of pregnancy, with clear escalation pathways for women in pre term labour or those requiring immediate ongoing care.

Training & Multi-Professional Learning — Enhanced Maternal Care

• 1.All staff caring for pregnant women must receive regular, structured multidisciplinary training to ensure timely recognition and effective management of the deteriorating woman. Training must equip midwives, obstetricians, anaesthetists, critical care teams, and outreach services with the skills, knowledge, and confidence to deliver safe, high-quality enhanced maternal care. Insights from simulation and team-based training should directly inform the development and refinement of clinical systems, processes, and pathways. Dedicated training time must be protected and recognised as part of mandatory training requirements, and trainers themselves must be appropriately trained.
• 2.National education programmes must cover key areas of maternal care and include the recognition and management of lesser-known but clinically important conditions, such as maternal ketosis, to ensure consistent, safe, and excellent care across all maternity services.

Risk Assessment Throughout Pregnancy — Delivering Safe, Personalised and Equitable Maternity Care Through Early Risk Recognition, Coordinated Care and Responsive Services

• 1.All Trusts must ensure women receive the appropriate 'safety-netting' within their care, enabling them to access services and treatments, including the consideration of reducing barriers to enable to the provision of safe maternity care.
• 2.All Trusts must ensure continuity of care for women, in particular, those with additional medical or social complexities.
• 3.All Trusts must ensure robust processes for information sharing between organisations to enable accurate risk-assessments, ensuring safe maternity care.
• 4.All Trusts and services (health, social care and education) involved with the care of families who have experienced a maternal death, must ensure that service provision is trauma-informed and family-centred.
• 5.All Trusts must ensure that pregnant and postnatal women receive timely imaging in the presence of concerning neurological symptoms.
• 6.Ensure that, where additional risk factors for maternal or fetal compromise are present, a lower threshold for admission is applied, with senior clinical review and consideration of Electronic Fetal Monitoring (EFM).

Risk Assessment Throughout Pregnancy — National standard for standardisation and recording of fetal growth risk assessment

• 1.There must be standardisation of fetal growth risk assessment, management and audit across RCOG (1), SBLCB (2) and NICE (3) guidance, with clear concise recommendations on the choice of pathways and charts to ensure consistency of the approach to the reduction in stillbirth.
• 2.All practitioners performing ultrasound growth scans should have training to undertake and report examinations to meet the standardised methods used in the recommended charts.

Risk Assessment Throughout Pregnancy — There must be a national standard and documentation for maternity triage and record keeping in maternity care provision

• 1.Trusts must develop a robust method of training for midwives providing triage care. This must include minimum competency standards for telephone risk assessment, agreed pathways for mandatory attendance for review and a holistic review of physical, mental and social wellbeing assessment.
• 2.Trusts must implement local assurance processes to monitor compliance against action 3 with triage call lines being recorded for quality and assurance purposes.
• 3.Trusts must develop auditable standards for the care and advice provided to women who: a. Contact telephone triage during pregnancy. b. Attend triage during the latent phase of labour. c. Receive maternity care during the latent phase or in early labour with the ability to differentiate between the latent phase of labour and labour that has failed to progress or has become complex/obstructed.
• 4.Suppliers of Electronic Patient Record (EPR) systems must ensure there is a standardised national maternity handover tool that addresses interoperability gaps between Trust systems. This tool must enable the consistent, real-time sharing of critical clinical information across organisational boundaries, particularly where women's care is being accessed outside of their maternity booking Trust.
• 5.All Trusts must implement the standardised national Maternity Early Warning System (MEWS) with clearly defined escalation pathways wherever they are being cared for. This will ensure the timely recognition, escalation and management of women who are becoming unwell, with rapid access to senior clinical support.
• 6.Trusts should have a mechanism in place to record images and reports/findings from ultrasound examinations across all settings.

Risk Assessment Throughout Pregnancy — Support the development and implementation of a structured assessment framework for the latent phase of labour, ensuring clarity when the 'latent phase of labour' becomes abnormal requiring escalation

1. Develop and implement a structured assessment framework for the latent phase of labour, incorporating maternal and fetal wellbeing, the woman's preferences and narrative, social circumstances, potential barriers to accessing care (e.g. language or socioeconomic factors), time of day, and distance from the unit when determining the appropriateness of admission.

Risk Assessment Throughout Pregnancy — All Trusts must define criteria for the safe use of telephone postnatal follow-up, indicating when telephone follow-up is acceptable or when face-to-face follow-up is mandatory

• 1.The first risk assessment for this should be documented in the woman's notes in the antenatal period (by 34 weeks gestation), and the risk assessment reviewed before postnatal discharge from the hospital, and after every postnatal community visit.
• 2.Trusts must develop lists of circumstances in which ALL postnatal follow-up should be face to face. Where a mother is advised to seek further medical review in relation to either maternal, or neonatal, care the responsibility for arranging appropriate follow-up lies with the healthcare professional providing that advice. Signposting alone is not sufficient. Whilst it is no longer stipulated in the Midwives standards (Nursing and Midwifery Council) that mothers and babies remain under the care of maternity services up to 28 days postnatal, women and families must be able to contact their maternity provider during this time if they wish or need too.

Risk Assessment Throughout Pregnancy — National standard for obstetric anaesthetic record-keeping

All Trusts must introduce and use standardised approaches to key areas of maternity anaesthetic care to reduce variation and improve outcomes.
Recommended examples include:
- management of inadequate epidural analgesia.
- intra-operative pain management and conversion to general anaesthesia.
- clear criteria for postnatal follow-up.
An agreed minimum standard for obstetric anaesthetic documentation must be implemented. This should include routine recording of intra-operative pain scores and accompanying narrative log, particularly during unexpected or critical events, capturing:
- the woman's symptoms and clinical findings.
- information shared with the woman and her involvement in decision-making.
- time of escalation and arrival of senior clinicians.
This approach will ensure that both the quality of clinical care and the woman's experience are consistently and accurately documented, supporting safe and personalised care.

Risk Assessment Throughout Pregnancy — Safe, accessible and comprehensive maternity anaesthetic documentation

• 1.All Trusts must strengthen maternal anaesthetic and critical care documentation, ensuring it is clear, contemporaneous, and readily accessible, ideally within a single unified electronic patient record.
• 2.Documentation must capture all relevant multidisciplinary discussions and care plans, and be woman-centred, reflecting the woman's needs, preferences, and involvement in decisions. This will support continuity of care, enhance safety, and enable personalised care across all clinical settings.

Risk Assessment Throughout Pregnancy — DHSC/NHSE should introduce and support access to coordinated multidisciplinary debrief and psychological support

• 1.DHSC/NHSE must support Trusts to ensure that maternity services provide timely, accessible psychological support for women and families following traumatic events.
• 2.This must include clear referral pathways, adequately resourced specialist provision, and processes that proactively identify and respond to unmet emotional and psychological needs. Improvement must be demonstrated through increased and equitable uptake of support services, high-quality family-feedback data confirming that families feel supported and safe, and evidence that psychological care is embedded as a core component of the maternity safety response.
• 3.All women who experience complex, unexpected or traumatic care must be offered a single, coordinated multidisciplinary debrief in a timely manner (to be agreed with the women/mother).
• 4.This must include access to psychological support and aim to minimise repeated visits, supporting recovery and reducing the risk of long-term psychological harm.
• 5.Where babies have experienced life-limiting conditions, severe brain injury, neonatal death or withdrawal of intensive care, services should provide support consistent with BAPM's palliative care framework and bereavement guidance.

Incident Investigation & Family Involvement — Funding for implementation of Maternity Patient Safety Incident Reporting Framework (PSIRF)

• 1.DHSC/NHSE must provide adequate funding to address the systemic resource gap that prevents Trusts from operationalising new national policy, enabling women and families to experience safer, more consistent care, with improvement demonstrated through full implementation, audit compliance, and sustained delivery of required standards. National guidance on maternity patient-safety incidents
• 2.DHSC/NHSE should develop clear maternity-specific definitions and guidance on patient-safety incidents to resolve national inconsistency in interpretation, ensuring women and families receive transparent and accurate reporting of harm, with improvement evidenced by nationally standardised grading and reliable national data.
• 3.Learning from neonatal PSIRF investigations should be considered alongside maternity investigations, recognising the opportunities for shared learning across perinatal services.
• 4.DHSC/NHSE must provide clear maternity-specific Duty of Candour guidance to address current uncertainty in applying DoC, ensuring families receive timely, accurate, and compassionate communication, with improvement measured through DoC compliance audits to standardise processes and reduce variation across Trusts.
• 5.DHSC/NHSE must develop to all staff at every level, the appropriate tier of PSIRF training aligned to their role to address current gaps in capability and confidence, so that women and families benefit from safer, more consistent learning responses, improvement demonstrated through role-specific training-compliance data, strengthened investigation quality, and clearer application of PSIRF principles across maternity services.
• 6.DHSC/NHSE should implement a nationally standardised, time-bound feedback framework within PSIRF to address current delays and inconsistency in post-investigation communication, ensuring that staff and families receive timely, clear, and compassionate updates that enhance trust and understanding, with improvement demonstrated through measurable reductions in feedback delays, strengthened family-reported experience, and evidence of learning being acted upon across providers. Consistency and equitable quality of feedback provided to families following all forms of investigation
• 7.DHSC/NHSE should establish a national standard for the quality, depth, and format of investigation outputs across all maternity investigation pathways - ensuring that, irrespective of whether care is reviewed through MNSI, PMRT, or local PSIRF processes. This will ensure all families consistently receive a comprehensive, compassionate, and clearly reasoned report that explains what happened, why, and what will change, thereby eliminating current inequities in the information. PSIRF training
• 8.Improve PSIRF implementation in Maternity Services Expand national training capacity in patient-safety science.
• 9.Embed PSIRF methodology in undergraduate and postgraduate curricula.
• 10.PSIRF methodology must be incorporated into medical, nursing, midwifery, RCOG, RCoA and NMC curricula to address the lack of foundational patient-safety education, ensuring future clinicians deliver safer care for women and families, with improvement demonstrated through curriculum adoption and competency assessments.

Governance & Board Accountability — Strengthened multidisciplinary governance and learning

All Trusts must ensure protected time for multidisciplinary governance, review and learning.
This must include learning from both adverse events and examples of good practice to support continuous improvement in the quality and safety of care provided to women. Learning from neonatal PSIRF investigations should be considered alongside maternity investigations, recognising the opportunities for shared learning across perinatal services.

Culture, Teamwork & Psychological Safety — Foster a compassionate, psychologically safe, and learning culture

All Trusts must actively foster a culture of safety, compassion, and respect across all maternity services. Staff must feel supported to speak up and raise concerns without fear of reprisal. Women must feel listened to, respected, and fully involved in decisions about their care.
Trusts must promote compassionate leadership, a civil and kind workplace, and the use of positive feedback as a tool to reinforce good practice and drive continuous improvement. A psychologically safe and learning culture is essential to improving clinical outcomes, supporting staff wellbeing, and enhancing the experiences of women and their families.
Appoint a maternity subject-matter specialist in every Trust
1. Every Trust must appoint a maternity subject-matter specialist with a nationally standardised role description to address inconsistent expertise and oversight, ensuring women receive safer, more consistent governance. The maternity subject-matter specialist will represent the views of the multidisciplinary maternity team (midwifery, obstetric, anaesthetic and neonatal) at trust board level. Improvement measured through compliance with Ockenden IEAs and other national review actions.

Culture, Teamwork & Psychological Safety — DHSC/NHSE should recommend and support recruitment processes and implement a consistent onboarding package for new starters

1. Trusts must streamline recruitment processes and implement a consistent onboarding package for all staff involved in the delivery of perinatal care with named supervision and support during initial shifts.

Mothers Who Have Died and Post Death Care — Mothers Who Have Died and Post Death Care National IEA:

• 1.All Trusts to ensure compliance, audited annually, with the NHS Records Management Code of Practice (2023). Post-Death Care:
• 1.Cease the practice of conducting post mortem examinations anywhere except the mortuary.
• 2.Ensure all deceased patients are fully - or if there is a valid technical reason, temporarily - reconstructed to a high standard immediately after their post mortem examination. If reconstruction must be delayed, the rationale for this decision should be recorded and referenced in subsequent condition checks of the deceased person, so there is a clear audit trail and timeline prior to final reconstruction.
• 3.Ensure all investigations or reviews into after-death care include an independent post-death care specialist.
• 4.Formally review all staff roles involved in the delivery of post-death care to: a. Map post-death care roles, responsibilities and scope of practice for each staff group. b. Identify points of crossover or duplication between each staff group. c. Define robust communication pathways for each staff group, for each post-death care process. National Action:
• 1.Introduce statutory regulation of Anatomical Pathology Technologists.
• 2.Ensure that paediatric post mortems of babies >12 weeks gestation are only undertaken by qualified Anatomical Pathology Technologists, specifically trained and competent in paediatric evisceration and reconstruction techniques.

The Trust must ensure Estimated Fetal Weight (EFW) calculation and EFW centiles are printed on the ultrasound report for all growth scans and that graphs that display growth velocity for fetal measurements and EFW are printed on the ultrasound report and include the 3rd/ 10th /90th /97th centile lines. This will ensure that clinical staff have clear information to plan appropriate management of a pregnancy.

The Trust must ensure a recalculation of risk at each contact with a referral to the appropriate specialist where risk categories change within the pregnancy, labour or postnatal pathway.

The Trust must develop and deliver training in the form of simulations, skills drills or case studies to support improved communication and actions for women requiring escalation/ transfer from triage/ the antenatal ward to labour ward.

The Trust must ensure adequate training and strategies in place to encourage staff to escalate and speak up, supporting midwifery clinical judgement and advocacy.

The Trust must promote the role of Professional Midwifery Advocate (PMA) supported reflective practice and restorative clinical supervision to empower staff voice and confidence.

The Trust is required to create a SOP and structured communication tool to ensure that staff are supported to safely transfer women when there is concern that requires immediate escalation for urgent one to one care.

Postpartum Haemorrhage (PPH)

The Trust must: achieve timely identification, escalation, and management of PPH across all NUH sites in alignment with Maternity Care Bundle (NHS England (2026) The Maternity Care Bundle).

Postpartum Haemorrhage (PPH)

Develop and implement a single, cross-site proforma for PPH to support consistent documentation.

Postpartum Haemorrhage (PPH)

Embed standardised escalation and reporting processes for PPH, aligned to local and national guidance.

Administration Support

The Trust must review administrative support capacity and processes to ensure sufficient resource to support timely development, review, and updating of clinical guidelines at NUH.

Administration Support

Establish patient safety related systems to track, monitor, and report progress against actions arising from meetings.

Communication and Guideline updates

The Trust must set clear, time-bound deadlines for actions, with defined accountability, and ensure structured dissemination of updates to guidelines.

Communication and Guideline updates

Conduct focus groups with a range of perinatal staff across a range of roles and multi professional levels to identify the most effective methods of communicating updates.

Communication and Guideline updates

Implement a standardised, multi-channel dissemination approach informed by staff feedback.

Neonatal

The Trust must ensure that the neonatal resuscitation guideline is changed to align with the Resuscitation Council UK Neonatal Life Support (NLS) algorithm, in terms of timing of progression from stage to stage.

Neonatal

Endotracheal tubes must not be 'pre-cut' or shortened until the correct length of insertion has been confirmed. Fixation methods must allow appropriate adjustment of the ET tube length after insertion.

Neonatal

The NUH feeding guideline for newborns must ensure sufficient 'safety netting' to identify the baby who is becoming seriously unwell. The differential diagnosis of poor feeding includes sepsis and significant neonatal illness. There must be improvement in multi-disciplinary education and training on recognition of the sick infant in the immediate post-natal period, in the hospital and community setting.

Neonatal

Antimicrobial stewardship must be strengthened. Both neonatal units must have 24/7 access to microbiology advice and a system of regular antibiotic reviews to support safe and effective antimicrobial use.

Neonatal

NUH must begin to implement strategies such as 'water free' care to reduce the risk of hospital acquired infections being transmitted via sinks and water. A plan must be developed no later that the end of December 2026.

Neonatal

NUH must review their threshold for the use of lumbar punctures to investigate neonatal sepsis, ensuring that they are always indicated, safe and used in line with national guidance.

Neonatal

NUH must develop simplified, unified, neonatal skin integrity documentation with clear accountability for pressure injury prevention, with a culture that prioritises prevention as well as treatment.

Neonatal

NUH must undertake regular audit of all airway fixation devices (ET, CPAP and HFNT) and perform patient safety reviews for all cases of tissue damage associated with such devices.

Clinical Governance — Close outstanding governance actions

NUH must ensure all outstanding actions from previous governance reviews, including the 2021 NUH Maternity Governance Review, are converted into SMART actions and prioritised for closure to address repeated failures. This will ensure women and families experience safer, more reliable care, with improvement demonstrated through timely completion and governance assurance reporting.

Clinical Governance — PSIRF training for Trust's senior leaders, at Executive level and within Divisions

The Trust must ensure that senior executives, the medical director, and nursing director complete the required PSIRF training - and that all staff are funded, released, and supported to attend - so that women and families benefit from safer, better-informed leadership, with improvement measured through training-compliance data and strengthened oversight.

Clinical Governance — Strengthening perinatal governance capacity and processes

The Trust must develop the perinatal governance team and ensure adequate staffing, resources, and training to address any current capacity gaps.

Clinical Governance — Strengthening perinatal governance capacity and processes

This must include a comprehensive review and strengthening of governance processes, alongside structured team development, so that women receive timely, high-quality investigations, learning responses, and feedback. Improvement must be evidenced through reduced investigation backlogs, enhanced quality and consistency of reports, and clear demonstration that learning is being acted upon and embedded across maternity services.

Clinical Governance — Strengthening Escalation Pathways and Board-Level Oversight

The Trust must ensure that Maternity Safety Champions provide visible, regular, and in-person engagement with maternity services and establish clear, reliable escalation pathways that enable front line concerns to reach Board level without delay or dilution. This is essential to close the gap between what women, families, and staff are reporting and what the Board is hearing. Women and families must experience a transparent, responsive safety culture in which their voices are listened to and acted upon.

Clinical Governance — Strengthening Escalation Pathways and Board-Level Oversight

Improvement must be demonstrated through documented compliance with visits, timely and traceable escalation of concerns, Board-level scrutiny and action, and staff feedback confirming that their voices are being heard and responded to.

Clinical Governance

Improvement of incident-reporting accessibility and culture. The Trust must ensure incident reporting is quick, simple, and actively encouraged to address under-reporting, enabling women and families to benefit from earlier identification of risks, with improvement measured through increased reporting rates and improved staff-survey feedback.

Clinical Governance — Families' experience inclusion in all investigations

The Trust must ensure that families' experiences are included in all learning responses to address gaps in understanding and improve the quality of investigations, so women and families feel heard and respected, with improvement demonstrated through audit of family involvement and enhanced learning outputs. Parents and families should be offered the opportunity to be actively included in all patient safety investigations, with clear, timely, communication regarding the findings

Clinical Governance — Psychological Support After Traumatic Events

The Trust must ensure timely, accessible psychological support for both families and staff following traumatic events. Families must have clear referral pathways and specialist provision, and staff must have access to Health and Wellbeing services, including TRiM and Second Victim support. Improvement should be demonstrated through increased uptake of support services, and feedback and wellbeing metrics showing that families and staff feel supported and safe.

Clinical Governance — Development of clear maternity-specific criteria for PSII and learning responses

The Trust must develop clear, maternity-specific criteria for determining when a PSII to address inconsistency and ambiguity or alternative learning response is required - supported by structured escalation and independent scrutiny ensuring women and families receive proportionate, transparent investigations, with improvement measured through consistent application at Trust corporate level and Trust-wide review of borderline cases.