Review of Maternity Services at Cwm Taf Health Board

Urgently review the systems in place for:
 data collection,
 clinical validation,
 checking the accuracy of data used to monitor clinical practice and outcomes,
 what information is supplied to national audits.

Identify nominated individuals (consultant obstetric lead and senior midwife) to ensure that all maternity unit guidelines:
 are up to date and regularly reviewed,
 are readily available to all staff, including locum staff and midwifery staff,
 have a multi-disciplinary approach,
 are adhered to in practice.

Mandate and support a full programme of clinically led audit with a nominated consultant lead to measure performance and outcomes against guidelines.

Ensure monitoring of clinical practice of all staff is undertaken by the Clinical Director and Head of Midwifery:
 to ensure compliance with guidelines,
 to ensure competency and consistency of performance is included in annual appraisal.

Agree a CTG training programme that includes a competency assessment which is delivered to all staff involved in the care of pregnant women, both in the antenatal period and intrapartum.

O&G consultant staff must deliver:
 a standard induction programme for all new junior medical staff
 a standard induction programme for all locum doctors.

Ensure an environment of privacy and dignity for women undergoing abortion or miscarriage in line with agreed national standards of care.

Ensure external expert facilitation to allow a full review of working practice to ensure:
 patient safety is considered at all stages of service delivery,
 a full review of roles and responsibilities within the obstetric team,
 the development and implementation of guidelines,
 an appropriately trained and supported system for clinical leadership,
 a long term plan and strategy for the service,
 there is a programme of cultural development to allow true multi-disciplinary working.

Develop a trigger list for situations which require consultant presence on the labour ward 3 which must be:
 agreed by all consultants in obstetrics, paediatrics and anaesthetics and senior midwives,
 audited and reported on the maternity dashboard.

Introduce regular risk management meetings which must be:
 open to all staff,
 conducted in an open and transparent way,
 held at a time and place to allow for maximum attendance

Ensure mandatory attendance at the following meetings for all appropriate staff. Attendance must be recorded and included in staff appraisals. Ensure that meetings are to be scheduled or elective clinical activity modified to allow attendance at:
 governance meetings,
 audit meetings,
 perinatal mortality meetings.

Undertake multidisciplinary debriefing sessions facilitated by senior maternity staff after an unexpected outcome.

Identify a clinical lead for governance from within the consultant body. This individual must:
 be accountable for good governance,
 attend governance meetings to ensure leadership and engagement.

Consultant meetings should:
 be regular in frequency,
 have a standing agenda item on governance,
 be joint meetings with anaesthetic and paediatric colleagues.

Educate all staff on the accountability and importance of risk management, Datix reporting and review and escalating concerns in a timely manner. Include this at:
 junior doctor induction,
 locum staff induction,
 midwifery staff induction,
 annual mandatory training.

Urgent steps must be taken to ensure that consultant obstetricians are immediately available when on call (maximum 30 minutes from call to being present).

Ensure training is provided for all SAS staff to ensure that they are:
 up to date with clinical competencies,
 skilled in covering high risk antenatal clinics and out-patient sessions.

Agree cohesive methods of consultant working after the merger with input from anaesthetic and paediatric colleagues.

Ensure that a system for the identification, grading and investigation of SIs is embedded in practice, through:
 appropriate training to key staff members,
 making investigations multidisciplinary and including external assessors.

Actively seek to remove the ‘blame culture’ to allow all staff to develop a willingness to report and learn from SIs.

Improve incident reporting by:
 delivering training on the use of the Datix system for all staff,
 encouraging the use of the Datix system to record clinical incidents,
 monitor the usage of the incident reporting system.

Actively discuss the outcomes of SIs in which individual consultants were involved in their appraisal.

Improve learning from incidents by sharing the outcomes from SIs on a regular basis and in an appropriate, regular and accessible format.

Identify a clinical lead from senior medical staff within the directorate to support the current midwifery governance lead.

Appoint a consultant and midwifery lead for clinical audit/quality improvement with sufficient time and support to fulfil the role to ensure:
 that clinical audits are multidisciplinary,
 that there is a clinically validated system for data collection,
 that the lead encourages all medical staff to complete an audit/quality improvement project each year to form part of their annual appraisal dataset,
 sharing of the outcomes of clinical audits and the performance against national standards.

Agree jointly owned neonatal and maternity services audits of neonatal service data including
 neonatal outcome data,
 perinatal deaths,
 transfer of term babies to SCBU,
 babies sent for cooling,
 Each Baby Counts reporting,
 MBRRACE reporting,
 breast feeding rates,
 skin to skin care after birth,
 neonatal infection,
 Baby Friendly accreditation
 Bliss baby charter accreditation

Consider extra resource to the Maternity Governance and Risk team to ensure:
 workload is manageable,
 that Datix are reviewed, graded and actioned in an appropriate and timely manner.

Ensure that the executive level lead role for maternity will work with the maternity department and this role is effective and supported. This individual should
 have a direct progress reporting responsibility to the Board, in particular while the issues raised in this report are being resolved
 understand and facilitate improvement in the reporting of safety issues and clinical risk,
 provide a single point of reference for liaison with external agencies,
 ensure all reports from external agencies and regulators are channelled through a single pathway to ensure priorities remain focussed.

Closely monitor bank hours undertaken by midwives employed by Cwm Taf, to ensure:
 the total number of hours is not excessive,
 the Health Board complies with the European Working Time Directive,
 these do not compromise safety.

Ensure the Medical Director has effective oversight and management of the consultant body by:
 making sure they are available and responsive to the needs of the service,
 urgently reviewing and agreeing job plans to ensure the service needs are met,
 clarifying what is to be covered as part of SPA activity (audit, governance, teaching, guidelines, data assurance, train more consultant obstetricians as appraisers),
 ensuring the most unwell women are seen initially by a consultant and all women are seen by a consultant within 12 hour NCEPOD recommendation4 (national standard).

Ensure a robust plan of births anticipated in each midwifery led unit and consultant led unit is undertaken
 ensure involvement of paediatric staff for all future service design reviews and actions

Ensure obstetric consultant cover is achieved in all clinical areas when required by:
 reviewing the clinical timetables to ensure that 12 hour cover per day on labour ward is achieved,
 undertake a series of visits to units where extended consultant labour ward presence has been implemented.
 considering working in teams to ensure a senior member of the team is available in clinics and provide cross cover for each other,
 considering the creative use of consultant time in regular hours and out of hours to limit the use of locums.

Actively share the findings of this RCOG review with the Welsh Deanery and urgently encourage them to revisit the Health Board to:
 reassess the quality of induction, training and supervision in obstetrics,
 seek assurance on the suitability of this service for trainees,
 appoint a named RCOG College tutor to provide support for the trainees currently on the RGH site with adequate time and resource to fulfill this function.

Allocate all trainees currently in post a clinical and educational supervisor
 the role of clinical supervisor and educational supervisor should be documented and closely monitored by the Director of Medical Education,
 the competency assessments for trainees must be provided in-house under the supervision of the RCOG College Tutor.

Undertake a training needs assessment for all staff to identify skills gaps and target additional training.

Clinical supervision and consultant oversight of practical procedures must be in place for all staff including specialist midwives and staff doctors.

Develop an effective department wide multi-disciplinary teaching programme.
 this must be adequately resourced and time allocated for attendance by all staff groups including specialist clinical midwives and SAS doctors.
 attendance must be monitored and reviewed at appraisal

Ensure the consultant on-call for the labour ward has ownership of all patients in the maternity unit for the period of call.
 this must involve the antenatal ward round being performed by the consultant.

Review the working practice for how consultant cover for gynaecology services will be delivered after the merger.
 a risk assessment must be performed to determine the case mix of planned surgery on the Royal Glamorgan site when there is no resident gynaecology cover.

Review the skills and competencies of the senior clinical midwives covering for tier 1 doctors to ensure:
 their scope of practice is clearly defined,
 the Health Board and the individuals are protected against litigation risk for their extended roles.

Consider the impact of the planned merger on the current culture of the organisation. The Board needs to carefully consider whether the planned merger of two units, both of which are described as having significant issues with their working culture, is likely to compound the problems rather than correct them.

In conjunction with Organisation Development undertake work with all grades of staff around communication, mutual respect and professional behaviours.
 staff must be held to account for poor behaviours and understand how this impacts on women’s safety and outcomes.

Undertake an in-depth assessment of the service as it moves into the future with its new ways of working and the likelihood of an increased demand for services.
 This can determine the structures and competencies of clinical leadership and governance that will support the service.

Support training in clinical leadership.
 The Health Board must allow adequate time and support for clinical leadership to function.

Provide mentorship and support to the Clinical Director
 define the responsibilities of this role,
 ensure there are measurable performance indicators,
 ensure informed HR advice to consistently manage colleagues’ absence and deployment of staff to cover the needs of the service,
 consider buddying with a Clinical Director from a neighboring Health Board.

Appoint clinical leads in a structure that supports the service with defined role descriptions and objectives to include an individual responsible for each of the following:
 governance and clinical quality to include guideline updating,
 data quality,
 medical staff education and training,
 multi-disciplinary training,
 audit,
 risk management,
 incident review,
 complaints handling.

Develop and strengthen the role and capacity of the MSLC to act as a hub for service user views and involvement of women and families to improve maternity care:
 Appoint a Lay Chair as a matter of priority and increase lay membership numbers with appropriate support and resources,
 Support lay members to engage with women using services in the FMU at RGH and at PCH to assess satisfaction and to identify issues relating to choices,
 Enhance the MSLC monitoring role in order to assess whether patterns of concerns are found and to ask for regular feedback on action taken.

Utilise the role and strengths of the Community Health Council:
 Ensure appropriate resources to act effectively as an independent advocate,
 Ensure that information is available to families regarding its role and contact details,
 Explore provision of CHC to act as point of contact and provide direct support for women and families, in addition to acting as a conduit referring to other agencies and support,
 Involve the CHC in the early implementation of the new maternity facilities at PCH and the FMU at RGH so they can be assured regarding the impact on access and satisfaction with maternity services.

Develop the range and scope of engagement with women and families.
 review the effectiveness of patient experience methodology and its impact on service change and improvement as a result of feedback,
 as a priority, review and address the monitoring of the outcomes of patient experience as a key part of the governance structure,
 feedback the outcomes of all engagement to women and families,
 explore methods to hear directly from women and families about their experience including patient stories, diaries, ‘mystery shopper’ or observation techniques.

Continue to work with and build on the community based engagement approaches being suggested by the MSLC.
 explore working with external partners, including the CHC and community based organisations.

Ensure responses to complaints and concerns is core to the work being undertaken to improve governance and patient safety:
 Review and enhance staff training on the value of listening to women and families,
 Review the process of investigation of concerns, compiling responses, handling ‘on the spot’ issues and ensure that all responses and discussions are informed by comprehensive investigations and accurate notes,
 Prioritise the key issues that women and families have highlighted to improve the response,
 Ensure that promises of sharing notes and providing reports to families are delivered,
 Clarify the process regarding the triangulation of the range of information sources on patient experience, SIs, complaints and concerns and other data and ensure that there is a rigorous approach to make sense of patterns of safety and quality issues,
 Review the learning from the SIs in relation to misdiagnosis, failure to seek a second opinion and inappropriate patient discharge.

Learn from the experience of women and families affected by events
 Respond and work with families in the way they require,
 Feed the learning into the design of a comprehensive training and support programme that will give women and families confidence in the skills, expertise, communication, safety and quality of maternity care.

Review the communications, support and engagement approach and strategy.
 Ensure that the focus is not solely on management of key messages,
 Demonstrate openness, honesty and transparency, admission of fault, and learning from this.

Prioritise an engagement programme with families at its heart.
 Women and families affected by events should be part of the improvement, co-design and culture change of the new service,

Review the level and effectiveness of the bereavement service.
 Ensure that appropriate support and counselling is available for all families as required,
 Consider implementing the National Bereavement Care Pathway5 which has been developed by Sands in collaboration with stakeholders including women and their families, RCOG and RCM.

Provide training for staff in communications skills, in particular on:
 Empathy, compassion and kindness.

Continue with efforts to recruit and retain permanent staff.

Seek expert external midwifery and obstetric advice for support in developing the maternity strategy and use the opportunity of change to explore new ways of working.

Urgently carry out a full risk assessment before committing to the merger on 9 March 2019 to ensure women’s safety, including:
 Ensuring that length of stay is reduced safely to allow for sufficient capacity in the new merged unit.

Monitor the effects of the reduced inpatient capacity to avoid any adverse effects on the safety or quality of the service.

Develop a plan to increase inpatient capacity if that is seen to be required.

Independent Board members must investigate the lack of action by the Executive Team and Board following receipt of the consultant midwife’s report in September 2018.
 Independent Board members must challenge the executive over the contents of this report,
 Independent Board members must ensure they are fully informed on the monitoring of planned improvements.

Independent Board members must challenge the quality of the data which informs the reports which they receive and rely upon for assurance.

Independent Board members should receive training in the implications of The Corporate Manslaughter and Corporate Homicide Act 2007 to better understand their role in ensuring the safety of the services which the Board provides.

Ensure that criteria for the opening of the new FMU have been agreed by a multidisciplinary maternity guidelines group and that readiness for the merger is assured.

Update the risk register and review regularly at Board level.

Develop a strategic vision for the maternity service and use the current opportunity of change to create a modern service which is responsive to the women and their families and the staff who provide care.

Consider examining other UK maternity services to seek out models for delivery which could better serve their population regarding:
 methods of service delivery,
 consultant delivered labour ward care,
 the role of and function of a resident consultant,
 achieving a balance between obstetrics and gynaecology commitments,
 reducing the use of SAS doctors for out of hours service delivery and developing their in hours role.

Identify and nurture the local leadership talent.

Ensure that any future service change for the development process of the maternity service as a whole is inclusive for all staff and service users.
 Ensure the service is adequately staffed to ensure that all staff groups are able to participate in developing the vision
 Consider an externally facilitated and supported process for review.
 Consider seeking continued support from HIW and the Royal Colleges to undertake a diagnostic review of the service particularly in relation to changes in service provisions.