1
Addressed to: The Trust Board
No Response Published
Link to recommendation 1
Recommendation · source text
All actions related to the 7 maternal deaths and the final action contained the Datix_Action plan, should be completed within the next 3 months. The Trust Board should maintain direct oversight of this completion and should not delegate that authority.
2
Addressed to: the Trust Board
No Response Published
Link to recommendation 2
Recommendation · source text
Governance:- the Trust Board should ensure that there is a robust maternity governance structure in place that supports clinical curiosity, robust review of cases, demonstrates an open and transparent process with involvement of service users. The governance processes put in place must provide assurance to the Board that maternity services can provide robust evidence in relation to closed actions and audits so that any changes to practice have been and remain effective. The Board must be assured that the organisation is a responsive learning organisation.
3
No Response Published
Link to recommendation 3
Recommendation · source text
Review the current VTE workstream, presently reported to the Quality Improvement Group, to ensure that appropriate and timely referral of high risk women into the antenatal service results in effective prophylaxis and that postnatal plans for future pregnancies are documented, accessible to primary care and there is evidence of the effectiveness of the pathways between primary and secondary care.
4
No Response Published
Link to recommendation 4
Recommendation · source text
Ensure that the major obstetric haemorrhage improvement work currently ongoing at the Trust includes evidence of appropriate escalation and attendance as per the Trust’s Policy and that processes within the Trust support attendance by relevant staff for obstetric emergencies.
5
Addressed to: the Trust
No Response Published
Link to recommendation 5
Recommendation · source text
Notwithstanding the current reorganisation of NHS England and ICBs, the Trust should engage with the ICB (or any subsequent organisation responsible for quality care across the County) and ensure that the two organisations can assure themselves that any pregnant women with a pre-existing medical condition, or a social concern that might affect pregnancy can access timely and effective care in the correct location, whether that is Council services (via the integrated locality partnership), primary or secondary care.