Recommendation · source text
The Trust would benefit from the development and implementation Perinatal workforce strategy to be developed inclusive of the review of current uplift and backfill for maternity leave
Source · Investigations in the NHS
Maternity Improvement Advisor Diagnostic Report Trust: The Leeds Teaching Hospitals NHS Trust
North East and Yorkshire
Published 01 Jul 2025
Trust Leeds Teaching Hospitals NHS Trust
Recommendations
Recommendation · source text
The Trust should consider reviewing the senior midwifery structure in line with Birthrate plus to provide assurance of strong leadership and visibility on both sites
Recommendation · source text
The Trust could consider the benefits of having maternity and neonatal services within the same CSU. Having maternity and neonatal services within the same CSU offers several strategic and clinical advantages that directly benefit patient outcome, care, continuity and operational efficiency.
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The Trust to consider the DoM portfolio to be just maternity and neonates with the focus on the Director of Midwifery and not Deputy Chief nurse.
Recommendation · source text
A review of the senior midwifery roles required to lead the service alongside a review of all interim roles would be beneficial to provide a higher level of assurance and removing the uncertainty for staff around interim roles.
Recommendation · source text
The Trust could benefit from reviewing and outlining key roles and responsibilities for the senior midwifery team to provide a higher level of assurance.
Recommendation · source text
The Trust to consider further investment in leadership programmes for the senior perinatal team to support ongoing development and succession planning.
Recommendation · source text
In response to the Birthrate plus report, the Trust should consider increasing the midwifery leadership structure to support clear cross site and site-specific cover to ensure assurance is provided around the quality and safety of the service and positive experiences for women and their families. Site specific matrons and flow midwives would further enhance the quality and safety of the services whilst also increasing the senior midwifery leadership team and improve the visibility and availability for immediate senior support in the clinical areas.
Recommendation · source text
The Trust should consider having a fully established Perinatal Leadership team with clear, terms of reference, lines of reporting and escalation, this will provide a higher level of oversight and assurance for the Trust board. The Perinatal Leadership Team should be inclusive of neonates and consideration for including anaesthetics and service user representation would ensure complete oversight of clinical services, risks and experience.
Recommendation · source text
The Trust should review the medical cover at the SJUH out of hours and appropriate escalation.
Recommendation · source text
Perinatal peer review should support depth of cross directorate working in relation to teamwork huddles.
Recommendation · source text
The Trust to review data around Neonatal Mortality, antenatal pathways and Saving Babies Lives v 3 (SBL) requirements.
Recommendation · source text
Due to the two large sites the Trust should consider increasing the midwifery leadership team by 14.45wte as recommended by Birthrate plus in March 2024. Consideration should include an additional HoM and DHoM and an increased Matron team to provide site specific leadership. An options appraisal has been produced and presented (Nov 2024), but it was not approved. This should be reconsidered to increase the quality and safety of the services.
Recommendation · source text
An additional Labour Ward Matron appointment should be prioritised. This was suggested during the Trust Board feedback.
Recommendation · source text
The community midwifery staffing establishment should be reviewed to align it towards the Birthrate plus recommendations. Consideration could be given to building an enhanced Continuity of Care (CoC) team due to the demographics and the local populations needs. A further consideration could be to support and improve areas in the inpatient settings such as Elective Caesarean Section (ELCS) staffing and flow coordinators. This will in turn change the planned roster numbers and give a more accurate reflection of fill rates as an indicator of safe staffing levels.
Recommendation · source text
The Trust Board should consider the approval to proactively recruit into the current maternity leave average i.e. 18wte Midwives to maintain the required fill rate on clinical rosters.
Recommendation · source text
The DoM role should be advertised substantively in the next 3 months to provide stability to the services. Given the scale and challenges of the service, the appointee should have significant midwifery leadership experience. The role should align with the RCM and RCOG leadership recommendations and not include any other clinical services other than maternity and neonates.
Recommendation · source text
When planning the future Midwifery Leadership Structure there should be consideration of the leadership capacity of the DoM. Either the DoM role should change to only include leadership of Maternity, or the HoM and/or Dep HoM numbers should increase.
Recommendation · source text
The Labour Ward establishment and roster templates should allow for additional midwives to be rostered when ELCS lists are running to avoid cancellations and escalation.
Recommendation · source text
There should be ongoing discussion regarding the appropriate staffing uplift for the midwifery establishment.
Recommendation · source text
A clear understanding of caseload numbers, safeguarding, complex pregnancies would provide a better oversight of the services and staff and service user requirements
Recommendation · source text
Review community midwifery services to ensure that they are correctly resourced by Midwives & MSW’s. This should also include a review of Interpreting services, estates, IT and consider enhanced CoC teams.
Recommendation · source text
Interpreting services should be reviewed across the service to ensure that they are fit for purpose and serve woman and families. Local resources created within the Trust should be reviewed and where possible used to support women with specific needs.
Recommendation · source text
The Trust should review the specialist midwifery requirement against current establishment to ensure that the service has the right staff to provide the quality and safety agenda to support women and families’ cross site
Recommendation · source text
The Trust should review current agreed remote working arrangements to ensure that staff are able to respond in a timely effective and efficient way to provide support when requited in critical escalation.
Recommendation · source text
Review the TNA to ensure that it covers all the mandatory requirements and encompasses a safety and learning update.
Recommendation · source text
Review how the education team, PMAs, fetal monitoring leads link into incident review and complaint processes.
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Review how compliance is monitored and escalated.
Recommendation · source text
Define and implement a seven-day bereavement support model with clear escalation and out-of-hours protocols.
Recommendation · source text
Consider Increasing staffing to at least 3–4 WTE bereavement midwives and/or support workers to meet demand across both sites.
Recommendation · source text
Standardise bereavement champion training and Rota presence to ensure every shift has a confident, capable staff member available.
Recommendation · source text
Finalise SOPs for families taking babies home, including hospice liaison, cuddle cot governance, and police notification guidance.
Recommendation · source text
Re-write the trust’s Handbook for Bereaved Parents, new version co-produced with service users with appropriate knowledge and/or lived experience and consider when and how this leaflet is provided, as well as how the arrival-in-hospital services it describes are delivered.
Recommendation · source text
Implement a bereavement suite environment checklist and ensure materials (leaflets, posters) are regularly reviewed and curated.
Recommendation · source text
Ensure memory making offers are revisited regularly throughout the inpatient stay, and that memory-making options are consistent across sites.
Recommendation · source text
Work with service user representatives to co-design and participate in staff training, simulation, and QI initiatives.
Recommendation · source text
Clarify family involvement options in PMRT processes and offer routine debriefs and explanation of grading where appropriate.
Recommendation · source text
Address corridor aesthetics and privacy issues near bereavement suite entrances and consider user-led walkarounds as part of improvement planning.
Recommendation · source text
Support the development of the existing PMA service by ensuring all the midwives who have trained as PMAs have enough allocated and dedicated time built into their rosters to facilitate meaningful interaction with staff this could be encompassed as part of the establishment review.
Recommendation · source text
Senior midwifery managers should share and discuss the results of the recent PMA survey of staff and encourage further promotion of the service.
Recommendation · source text
The Trust should consider improving the visibility of the PMA team and service which will benefit the staff.
Recommendation · source text
Ensure the lead PMA can liaise with the regional lead PMA which will enable innovation within the services.
Recommendation · source text
Consider a lead PMA role that can focus solely on PMA activity.
Recommendation · source text
Expand the team of PMAs: plan the recruitment and development of future PMAs in line with robust TNA.
Recommendation · source text
Involve the PMAs in all QI work across the division with improved accountability within the department and across the Trust
Recommendation · source text
Team coordinators to fully understand the role of the PMA and encourage greater autonomy of the group
Recommendation · source text
Consider celebration events for PMAs, staff to involve women and families.
Recommendation · source text
The Trust would benefit having a quarterly review of recruitment and retention performance to maintain oversight of attrition rates and which may enable earlier intervention.
Recommendation · source text
An established funded role would be beneficial in supporting ongoing recruitment and retention
Recommendation · source text
To understand current vacancy rate and triangulate with the reported fill rates.
Recommendation · source text
Actions should be expedited to ensure that the is 24/7 availability of Cell Salvage for Maternity Theatres at the LGI. Either by allocating a specific machine to maternity (with the appropriate maintenance and checking in place) or by ensuring there is a wider pool of machines available across the site.
Recommendation · source text
Staff should be encouraged to report any incident relating to Cell Salvage availability. This should be monitored and reported up to Trust Board.
Recommendation · source text
There should be regular feedback to the Board Safety Champions regarding progress with this concern.
Recommendation · source text
This Clinical Risk does not appear on the Obstetric Risk Register Report (17/3/25). Consideration should be given to undertaking a Risk Assessment and escalating this to the Risk Register.
Recommendation · source text
Review consent process in line with service user feedback
Recommendation · source text
Explore cross site telephone triage for consistency and improved access for women providing privacy
Recommendation · source text
Review and relaunch BSOTS in collaboration with staff
Recommendation · source text
Review policy for non-attenders to ensure that these women are contacted and offered a further conversation and to attend if required
Recommendation · source text
Review current medical staff rota and availability to ensure that women are reviewed as per pathway and reduce the risk of an adverse outcome due to delays of obstetric medical review.
Recommendation · source text
The Trust Communications and Estates teams should undertake work to bring the unique identity and wayfinding standard for maternity areas to the same standard as The Children’s Hospital.
Recommendation · source text
Review current pathways to strengthen the service
Recommendation · source text
Oversight of the letters prior to them being sent to families to ensure a compassionate and proportionate response that is reflective of the lived experience.
Recommendation · source text
The Trust should identify all vital equipment that requires replacing and develop a clear trajectory, risk assessment and mitigation plan. Ensuring that this is visible on the risk register
Recommendation · source text
Ensure there is oversight of all equipment that needs replacing to maintain a clear trajectory for delivery.
Recommendation · source text
The Maternity teams should be escalating risks to the Safety Champions for this to be raised at the Trust board. The roles of the safety champions should be reviewed to ensure clear roles and responsibilities and accountability to raise concerns.
Recommendation · source text
To review the current structure to ensure there is the correct WTE to provide a robust, responsive and learning approach to untoward incidents.
Recommendation · source text
There is an opportunity develop a communication strategy to promote effective learning
Recommendation · source text
The development of a strong governance framework would be beneficial to be shared with all staff outlining roles, responsibilities and accountability.
Recommendation · source text
The Trust would benefit from reviewing the current complaint processes and pathways with consideration to contacting the service user by phone when the complaint is reviewed to promote a more compassionate and transparent response. Ensuring that the members of the team have had the relevant training to enable them to respond in a kind and compassionate way and changing the terminology to patient experience midwife rather than complaints midwife would all be a positive step forward.
Recommendation · source text
The PMRT process would benefit from a full review to ensure that it remains service user focused, and that learning is able to be clearly articulated.
Recommendation · source text
A review of the letters’ sent to families and how families want to receive feedback would be beneficial to ensure a compassionate and service user led approach
Recommendation · source text
It would be beneficial for the Trust to have complete oversight of themes of incidents to identify any trends to ensure the Trust is responsive to ensuring the ongoing safety of staff and service users.
Recommendation · source text
The Trust should consider engaging with NHSR and undertaking the offer of training to demonstrate a willingness to continually improve services, outcome ad experience.
Recommendation · source text
A specific quality and safety report should be presented as a minimum of quarterly alongside a Biannual perinatal specific workforce report. The MIAs can provide example templates of these to ensure more robust oversight of the quality and safety of services.
Recommendation · source text
The current meeting structure within maternity could benefit from being reviewed alongside current TOR to ensure the right level of documents and escalation is provided with appropriate check and challenge to gain high level assurance and be aware of blind spots and red flags within the service.
Recommendation · source text
To review the requirements of MIS and current reporting mechanisms to ensure ongoing compliance with safety action 9.
Recommendation · source text
The safety champions and their roles should be defined and shared with all staff.
Recommendation · source text
Safety champions to review how staff and service user engagement could be enhanced.
Recommendation · source text
Develop a midwifery and obstetric escalation SOP to support staff and senior midwives when managing high activity / acuity and rota deficits.
Recommendation · source text
Review and strengthen the roles of the flow midwives to always be site specific with an onsite presence. These roles are pivotal in ensuring minimising delays in clinical care and supporting cross site planned and unplanned activity.
Recommendation · source text
The Trust should consider strengthening strategic communication and visibility and clearly cascading the Improvement Strategy to all staff levels.
Recommendation · source text
Align existing QI projects as part of a unified Perinatal Improvement Plan.
Recommendation · source text
Encourage staff participation of QI training, with an emphasis on high-impact roles (e.g., specialist midwives, ward managers, matrons) and set up clear expectations of applying the learning on on-going initiatives.
Recommendation · source text
Incorporate QI training into appraisals and personal development plans.
Recommendation · source text
Develop process to monitor QI training uptake e.g. by education, HR, and clinical leadership.
Recommendation · source text
Expand visibility and involvement of senior leaders across both sites.
Recommendation · source text
Iidentify a small number of high-priority- or complex initiatives- requiring targeted QI focus.
Recommendation · source text
Transition the maternity dashboard from a RAG rating system to Statistical Process Control SPC) charts to enable more robust analysis of trends, variation, and performance over time and provide necessary training to staff
Recommendation · source text
Undertake a Structured QI project to improve leadership behaviours, culture and staff engagement
Recommendation · source text
Address the effective implementation of BSOTS as a QI project where staff and service users contribute to identify robust and sustainable solutions, including refreshed training for all clinical staff (medical and midwifery).
Recommendation · source text
Set clear expectations that key staff (e.g. ward managers, specialist midwives, matrons) lead and participate in QI, with responsibilities reflected in job descriptions, appraisals, and development plans.
Recommendation · source text
Review Perfect Ward expectations for maternity, ensure audit content is relevant and meaningful.
Recommendation · source text
Consider implementing and maintaining QI huddles and QI boards accessible to staff to application of QI methodology and staff engagement to enhance staff engagement, support continuous improvement efforts, and improve the application of QI methodology.
Recommendation · source text
Working with MNVP on specific co-produced areas of improvement work especially the environment.
Recommendation · source text
Ensuring the MNVP is a core member of all meetings and is included in key midwifery recruitment.
Recommendation · source text
The Trust would benefit from reviewing and engaging the MNVP in the safety champions meetings and meet with the Non-Executive Director (NED) for Maternity services on a regular basis
Recommendation · source text
The Trust would benefit from some focused cultural work and support form ward to board to ensure that leaders and staff feel psychologically safe to raise concerns that will be listened to and supported.
Recommendation · source text
The Trust should review the hierarchical structure to ensure a more even power base
Recommendation · source text
Consideration of a communication strategy with input from staff to ensure this captures all methods of effective communication of key messages
Recommendation · source text
The Trust would benefit from site specific midwifery leadership roles as previously described
Recommendation · source text
Strengthening the relationship between clinical teams, safety champions, and senior management is essential. This might include more leadership sessions on the shop floors to provide direct support and a clearer chain of feedback and executive accountability.
Acceptance status
No Response Published
101
Total recommendations
101