1
Addressed to: NHS England
Accepted
Link to recommendation 1
Recommendation · source text
Prompt establishment of a task force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use.
View response
Accepted. NHS England established the Reading the Signals Data Co-ordination Group and the Maternity and Neonatal Outcomes Group to develop clinical outcome measurement tools for mandatory national use.
2i
Addressed to: Those responsible for clinical education
Accepted
Link to recommendation 2i
Recommendation · source text
Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning.
View response
Accepted. DHSC coordinating mapping of compassionate care teaching across professions with royal colleges and regulators.
2ii
Addressed to: Royal colleges, professional regulators, employers
Accepted
Link to recommendation 2ii
Recommendation · source text
Relevant bodies, including royal colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance.
View response
Accepted. DHSC leading three-part approach: map oversight responsibilities, share good practice, identify gaps.
3i
Addressed to: RCOG, RCM, Royal College of Paediatrics and Child Health
Accepted
Link to recommendation 3i
Recommendation · source text
Relevant bodies, including RCOG, RCM and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset.
View response
Accepted. Royal colleges commissioned to report on teamwork barriers and solutions. PROMPT training incentivised via maternity incentive scheme.
3ii
Addressed to: Health Education England, royal colleges, employers
Accepted
Link to recommendation 3ii
Recommendation · source text
Relevant bodies, including Health Education England, royal colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development.
View response
Accepted. Reviews examining support structures for junior doctors, SAS doctors, and locums.
4i
Addressed to: HM Government
Accepted
Link to recommendation 4i
Recommendation · source text
The government reconsiders bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies.
View response
Accepted. Government noted existing statutory duty of candour and committed to address alongside the response to Bishop James Jones' 2017 Hillsborough report regarding broader legislative protections for families.
4ii
Addressed to: NHS trusts
Accepted
Link to recommendation 4ii
Recommendation · source text
Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards.
View response
Accepted. NHS England asked all trusts to review their approaches at board meetings. Executive and non-executive maternity/neonatal board safety champions to be appointed.
4iii
Addressed to: NHS England
Accepted
Link to recommendation 4iii
Recommendation · source text
NHS England reconsiders its approach to poorly performing trusts, with particular reference to leadership.
View response
Accepted. Recovery Support Programme deploys improvement directors to challenged trusts. Broader leadership reviews (Messenger Review, Kark Review) underway.