Trust Board Meeting: Wednesday 8 July 2014
TB2015.86
Title
Kirkup Report 2015
Gap Analysis, Maternity Services
Oxford University Hospitals NHS Trust
Status
For Information
History
This is a new paper
Board Lead(s)
Catherine Stoddart, Chief Nurse
Key purpose
Strategy
Assurance
TB2015.86 Kirkup Report 2015, Gap Analysis, Maternity Service
Policy
Performance
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Oxford University Hospitals
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Executive Summary
1. This paper provides the Board with an overview of the recommendations from the
Kirkup report and a gap analysis for the Trust.
2. The Kirkup report was written following an independent investigation into the
management, delivery and outcomes of care provided by the maternity and neonatal
services at the University Hospitals of Morecambe Bay NHS Foundation Trust from
2004 to 2013. There were some serious failings identified as part of the review.
3. A National Review of Maternity services has been set up following the Kirkup report
and a working party agreed. The review is being led by Baroness Julia Cumberledge.
The timescale for reporting is the end of 2015.
4. A gap analysis has been completed in relation to maternity services provided by Oxford
University Hospitals NHS Trust.
The analysis has been completed using the
recommendations from the Kirkup report; the table forms the basis of this paper.
5. The findings of the Kirkup Report were related to failings at almost every level from the
maternity unit to those responsible for regulating and monitoring the Trust. The
investigation found 20 instances of significant or major failures of care at Furness
General Hospital, associated with three maternal deaths and the deaths of 16 babies at
or shortly after birth. Different clinical care in these cases would have been expected to
prevent the outcome in one maternal death and the deaths of 11 babies.
6. The issues identified broadly include;
1. Substandard clinical competence of clinicians involved (midwifery, paediatrics
and obstetrics)
2. Pursuit of normal birth at any cost with insufficient recognition of risk
3. Dysfunctional Team working
4. Inadequate clinical investigations over several years including reliance on poor
quality internal governance systems
5. External oversight was inadequate during the process of seeking foundation
trust status and a development approach was used. This included CQC Monitor,
PHSO and NW SHA.
(appendix 1)
7. The Trust and its maternity service generally complies with the majority of the
recommendations of the Kirkup report. Where there are gaps and additional action
required, these are detailed in the attached document. The main areas include:
 The need to agree a new structure and process in readiness for the anticipated
replacement of the framework for Supervision of Midwives (pending legislative
change still awaited);
 Ensure that smaller maternity units have senior midwifery management and
obstetric presence to support staff and manage issues as they arise.
 Finalise the maternity strategy.
 Maintain regular review of clinical incidents, identify themes and implement
changes as appropriate.
 Keep the number of hours of Consultant presence under regular review.
 Further develop the process to audit clinical guidelines.
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8. Recommendation
The Trust Board is asked to:

Note the Kirkup report, found at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/4084
80/47487_MBI_Accessible_v0.1.pdf ; and

Note the ongoing work that will be undertaken in response to the Kirkup report.
Catherine Stoddart
Chief Nurse
July 2015
Report prepared by Jane Herve
Head of Midwifery
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Kirkup Report 2015, Gap Analysis, Maternity services Oxford University Hospitals Trust (OUHT)
1.
Recommendations for the NHS
1.1 There are a range of recommendations that require consideration by Trusts who delivery Maternity services and for those
bodies responsible for leading and ensuring that action is completed.
1.2 Where appropriate information about practices and services across the OUHT and any gaps and actions required have been
included. This gap analysis will form the basis of an action plan for OUHT against the Kirkup report.
1.3 The recommendations and numbers have been copied directly from the Kirkup report.
NUMBER
RECOMMENDATION
OUHT
19
In light of the evidence we have heard during the
Investigation, we consider that the professional
regulatory bodies should review the findings of this
Report in detail with a view to investigating further the
conduct of registrants involved in the care of patients
during the time period of this Investigation. Action:
the General Medical Council, the Nursing and
Midwifery Council.
There should be a national review of the provision of
maternity care and paediatrics in challenging
circumstances, including areas that are rural, difficult
to recruit to, or isolated. This should identify the
requirements to sustain safe services under these
conditions. In conjunction, a national protocol should
be drawn up that defines the types of unit required in
different settings and the levels of care that it is
appropriate to offer in them. Action: NHS England,
the Care Quality Commission, the Royal College
of Obstetricians and Gynaecologists, the Royal
College of Midwives, the Royal College of
Paediatrics and Child Health, the National Institute
for Health and Care Excellence.
Requires national response
20
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Requires national response
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GAP’s and ACTIONS REQUIRED
Oxford University Hospitals
21
The challenge of providing healthcare in areas that
are rural, difficult to recruit to or isolated is not
restricted to maternity care and paediatrics. We
recommend that NHS England consider the wisdom
of extending the review of requirements to sustain
safe provision to other services. This is an area
lacking in good-quality research yet it affects many
regions of England, Wales and Scotland. This should
be seen as providing an opportunity to develop and
promote a positive way of working in remote and rural
environments. Action: NHS England.
22
We believe that the educational opportunities afforded
by smaller units, particularly in delivering a broad
range of care with a high personal level of
responsibility, have been insufficiently recognised and
exploited. We recommend that a review be carried out
of the opportunities and challenges to assist such
units in promoting services and the benefits to larger
units of linking with them. Action: Health Education
England, the Royal College of Obstetricians and
Gynaecologists, the Royal College of Paediatrics
and Child Health, the Royal College of Midwives
23
Clear standards should be drawn up for incident
reporting and investigation in maternity services.
These should include the mandatory reporting and
investigation as serious incidents of maternal deaths,
late and intrapartum stillbirths and unexpected
neonatal deaths. We believe that there is a strong
case to include a requirement that investigation of
these incidents be subject to a standardised process,
which includes input from and feedback to families,
and independent, multidisciplinary peer review, and
should certainly be framed to exclude conflicts of
interest between staff. We recommend that this build
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Given the configuration of
maternity
services
across
Oxfordshire, the Trust would
support the proposal for further
research.
OUHT offers student midwife None
placements in a tertiary referral
maternity
service;
district
general hospital maternity unit;
free standing and co-located
maternity units; and community
midwifery
care.
The
evaluations
are
extremely
positive and students gain
experience in the breadth of
midwifery practice.
Incident reporting in maternity None
services is embedded in the
culture
of
the
maternity
service; all staff are aware of
when/how to report incidents.
Investigations are completed in
line with Trust and National
standards.
Reporting is through the
Women’s Clinical Governance
Committee and to Trust Risk
Management.
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on national work already begun on how such a
process would work. Action: the Care Quality
Commission, NHS England, the Department of
Health.
24
We commend the introduction of the duty of candour
for all NHS professionals. This should be extended to
include the involvement of patients and relatives in the
investigation of serious incidents, both to provide
evidence that may otherwise be lacking and to receive
personal feedback on the results. Action: the Care
Quality Commission, NHS England.
25
26
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Feedback is provided to the
family along with a copy of the
report.
The maternity service actively None
supports the duty of candour.
Following any serious incident
the family is offered an
opportunity to meet with a
Consultant, a Supervisor of
Midwives
or
Midwifery
Manager to ensure they have
the opportunity to input into the
investigation process.
We recommend that a duty should be placed on all This requires a national
NHS Boards to report openly the findings of any response
external
investigation
into
clinical
services,
governance or other aspects of the operation of the
Trust, including prompt notification of relevant external
bodies such as the Care Quality Commission and
Monitor. The Care Quality Commission should
develop a system to disseminate learning from
investigations to other Trusts. Action: the
Department of Health, the Care Quality
Commission.
We commend the introduction of a clear national OUHT has a clear policy which
policy on whistleblowing. As well as protecting the is available for all staff to
interests of whistleblowers, we recommend that this is access on the Intranet.
implemented in a way that ensures that a systematic
and proportionate response is made by Trusts to
concerns identified. Action: the Department of
Health.
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27
Professional regulatory bodies should clarify and
reinforce the duty of professional staff to report
concerns about clinical services, particularly where
these relate to patient safety, and the mechanism to
do so. Failure to report concerns should be regarded
as a lapse from professional standards. Action: the
General Medical Council, the Nursing and
Midwifery Council, the Professional Standards
Authority for Health and Social Care.
28
Clear national standards should be drawn up setting
out the professional duties and expectations of clinical
leads at all levels, including, but not limited to, clinical
directors, clinical leads, heads of service, medical
directors, nurse directors. Trusts should provide
evidence to the Care Quality Commission, as part of
their processes, of appropriate policies and training to
ensure that standards are met. Action: NHS
England, the Care Quality Commission, the
General Medical Council, the Nursing and
Midwifery Council, all Trusts.
29
Clear national standards should be drawn up setting
out the responsibilities for clinical quality of other
managers, including executive directors, middle
managers and non-executives. All Trusts should
provide evidence to the Care Quality Commission, as
part of their processes, of appropriate policies and
training to ensure that standards are met. Action:
NHS England, the Care Quality Commission, all
Trusts.
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OUHT Supervisor of Midwives
discuss the whistleblowing
policy with all their supervisees
during their annual review.
Awaiting development of clear
national standards
Awaiting development of clear
national standards
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Oxford University Hospitals
30
A national protocol should be drawn up setting out the
duties of all Trusts and their staff in relation to
inquests. This should include, but not be limited to,
the avoidance of attempts to ‘fend off’ inquests, a
mandatory requirement not to coach staff or provide
‘model answers’, the need to avoid collusion between
staff on lines to take, and the inappropriateness of
relying on coronial processes or expert opinions
provided to coroners to substitute for incident
investigation. Action: NHS England, the Care
Quality Commission.
31
The NHS complaints system in the University
Hospitals of Morecambe Bay NHS Foundation Trust
failed relatives at almost every turn. Although it was
not within our remit to examine the operation of the
NHS complaints system nationally, both the nature of
the failures and persistent comment from elsewhere
lead us to suppose that this is not unique to this
Trust. We believe that a fundamental review of the
NHS complaints system is required, with particular
reference to strengthening local resolution and
improving its timeliness, introducing external scrutiny
of local resolution and reducing reliance on the
Parliamentary and Health Service Ombudsman to
intervene in unresolved complaints. Action: the
Department of Health, NHS England, the Care
Quality Commission, the Parliamentary and
Health Service Ombudsman.
32
The Local Supervising Authority system for midwives
was ineffectual at detecting manifest problems at the
University Hospitals of Morecambe Bay NHS
Foundation Trust, not only in individual failures of
care but also with the systems to investigate them. As
with complaints, our remit was not to examine the
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A national response is required
Complaints are managed in External scrutiny – a system is
line with Trust and national not currently in place.
standards.
Meetings are offered to some
complainants to try to resolve
their concerns in a proactive
way.
Incidents and complaints are
discussed on a monthly basis
in a multi-professional forum.
Recurrent
themes
are
identified and investigated by
the
Women’s
Clinical
Governance team.
The Head of Midwifery has Plan to be
proposed a new structure and implemented.
process to replace Supervision
of
Midwives,
upon
its
anticipated removal from the
legal framework (subject to
Page 8 of 20
agreed
and
Oxford University Hospitals
operation of the system nationally; however, the
nature of the failures and the recent King’s Fund
review (Midwifery regulation in the United Kingdom)
lead us to suppose that this is not unique to this
Trust, although there were specific problems there
that exacerbated the more systematic concern. We
believe that an urgent response is required to the
King’s Fund findings, with effective reform of the
system. Action: the Department of Health, NHS
England, the Nursing and Midwifery Council.
33
TB2015.86
legislative change, which is still
awaited). It is proposed that a
professional advisory board
will be established that will
offer support to midwives,
assist with investigations and
service developments.
The Head of Midwifery is
working with the Lead Midwife
for Education at Oxford
Brookes University to develop
an
appropriate
academic
package for the individual
members of the professional
board.
We considered carefully the effectiveness of
This requires a national
separating organisationally the regulation of quality by
response
the Care Quality Commission from the regulation of
finance and performance by Monitor, given the close
inter-relationship between Trust decisions in each
area. However, we were persuaded that there is more
to be gained than lost by keeping regulation
separated in this way, not least that decisions on
safety are not perceived to be biased by their
financial implications. The close links, however,
require a carefully coordinated approach, and we
recommend that the organisations draw up a
memorandum of understanding specifying roles,
relationships and communication. Action: Monitor,
the Care Quality Commission, the Department of
Health.
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34
The relationship between the investigation of
individual complaints and the investigation of the
systemic problems that they exemplify gave us cause
for concern, in particular the breakdown in
communication
between
the
Care
Quality
Commission and the Parliamentary and Health
Service Ombudsman over necessary action and
follow-up. We recommend that a memorandum of
understanding be drawn up clearly specifying roles,
responsibilities,
communication
and
follow-up,
including explicitly agreed actions where issues
overlap. Action: the Care Quality Commission, the
Parliamentary and Health Service Ombudsman.
35
The division of responsibilities between the Care
Quality Commission and other parts of the NHS for
oversight of service quality and the implementation of
measures to correct patient safety failures was not
clear, and we are concerned that potential ambiguity
persists. We recommend that NHS England draw up a
protocol that clearly sets out the responsibilities for all
parts of the oversight system, including itself, in
conjunction with the other relevant bodies; the starting
point should be that one body, the Care Quality
Commission, takes prime responsibility. Action: the
Care Quality Commission, NHS England, Monitor,
the Department of Health.
36
The cumulative impact of new policies and
processes, particularly the perceived pressure to
achieve Foundation Trust status, together with
organisational reconfiguration, placed significant
pressure on the management capacity of the
University Hospitals of Morecambe Bay NHS
Foundation Trust to deliver against changing
requirements whilst maintaining day-to-day needs,
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This will require a national
response however locally
complaints are considered in
light of PHSO reviews.
This requires a national
response
Following the DH review, the
Trust will review its current
practices in relation to the
impact of policy changes on
the Trust
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Oxford University Hospitals
including safeguarding patient safety. Whilst we do
not absolve Trusts from responsibility for prioritising
limited capability safely and effectively, we
recommend that the Department of Health should
review how it carries out impact assessments of new
policies to identify the risks as well as the resources
and time required. Action: the Department of
Health.
37
Organisational change that alters or transfers
responsibilities and accountability carries significant
risk, which can be mitigated only if well managed. We
recommend that an explicit protocol be drawn up
setting out how such processes will be managed in
future. This must include systems to secure retention
of both electronic and paper documents against future
need, as well as ensuring a clearly defined transition
of responsibilities and accountability. Action: the
Department of Health.
38
Mortality recording of perinatal deaths is not
sufficiently systematic, with failures to record properly
at individual unit level and to account routinely for
neonatal deaths of transferred babies by place of
birth. This is of added significance when maternity
units rely inappropriately on headline mortality figures
to reassure others that all is well. We recommend that
recording systems are reviewed and plans brought
forward to improve systematic recording and tracking
of perinatal deaths. This should build on the work of
national audits such as MBRRACE-UK, and include
the provision of comparative information to Trusts.
Action: NHS England.
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The Trust has robust systems
for information governance
regarding retention of
documents
Stillbirths and neonatal deaths Continue to monitor, review
are recorded on the Electronic and report.
Patient record and BadgerNet.
The information is collected on
the maternity Dashboard and
discussed at the Women’s
Clinical
Governance
Committee, Intrapartum group
and Trust Clinical Governance
Committee.
The Maternity Dashboard is
also included in Monthly
Divisional
Quality
and
Performance Report which is
reviewed
at
Divisional
Executive
meetings
and
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Oxford University Hospitals
39
There is no mechanism to scrutinise perinatal deaths
or maternal deaths independently, to identify patient
safety concerns and to provide early warning of
adverse trends. This shortcoming has been clearly
identified in relation to adult deaths by Dame Janet
Smith in her review of the Shipman deaths, but is in
our view no less applicable to maternal and perinatal
deaths, and should have raised concerns in the
University Hospitals of Morecambe Bay NHS
Foundation Trust before they eventually became
evident. Legislative preparations have already been
made to implement a system based on medical
examiners, as effectively used in other countries, and
pilot schemes have apparently proved effective. We
cannot understand why this has not already been
implemented in full, and recommend that steps are
taken to do so without delay. Action: the
Department of Health.
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Performance Reviews with
Executive Directors, and with
effect from September 2015 is
to be included in the Quality
Report submitted to the Trust
Board, and to the Quality
Committee
in
alternate
months.
This requires a national
response
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Oxford University Hospitals
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40
Given that the systematic review of deaths by medical This awaits the national
examiners should be in place, as above, we response to recommendation
recommend that this system be extended to stillbirths 39 (see above)
as well as neonatal deaths, thereby ensuring that
appropriate recommendations are made to coroners
concerning the occasional need for inquests in
individual cases, including deaths following neonatal
transfer. Action: the Department of Health.
41
We were concerned by the ad hoc nature and variable
This awaits a national
quality of the numerous external reviews of services
response from the relevant
that were carried out at the University Hospitals of
colleges
Morecambe Bay NHS Foundation Trust. We
recommend that systematic guidance be drawn up
setting out an appropriate framework for external
reviews
and
professional
responsibilities
in
undertaking them. Action: the Academy of Medical
Royal Colleges, the Royal College of Nursing, the
Royal College of Midwives.
42
We further recommend that all external reviews of
This will require a national
suspected service failures be registered with the Care
response
Quality Commission and Monitor, and that the Care
Quality Commission develops a system to collate
learning from reviews and disseminate it to other
Trusts. Action: the Care Quality Commission,
Monitor.
43
We strongly endorse the emphasis placed on the The Trust will review its local
quality of NHS services that began with the Darzi
arrangements for maternity
review, High Quality Care for All, and gathered care provision in line with the
recommendations of High
importance with the response to the events at the Mid
Quality Care for All
Staffordshire NHS Foundation Trust. Our findings
confirm that this was necessary and must not be lost.
We are concerned that the scale of recent NHS
reconfiguration could result in new organisations and
post-holders losing the focus on this priority. We
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Oxford University Hospitals
recommend that the importance of putting quality first
is re-emphasised and local arrangements reviewed to
identify any need for personal or organisational
development, including amongst clinical leadership in
commissioning organisations. Action: NHS England,
the Department of Health.
44
This Investigation was hampered at the outset by the
lack of an established framework covering such
matters as access to documents, the duty of staff and
former staff to cooperate, and the legal basis for
handling evidence. These obstacles were overcome,
but the need to do this from scratch each time an
investigation of this format is set up is unnecessarily
time-consuming. We believe that this is an effective
investigation format that is capable of getting to the
bottom of significant service and organisational
problems without the need for a much more
expensive, time-consuming and disruptive public
inquiry. This being so, we believe that there is
considerable merit in establishing a proper framework,
if necessary statutory, on which future investigations
could be promptly established. This would include
setting out the arrangements necessary to maintain
independence and work effectively and efficiently, as
well as clarifying responsibilities of current and former
health service staff to cooperate. Action: the
Department of Health.
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This requires a national
response
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Oxford University Hospitals
2.
Chapter Three: Clinical Services
NUMBER CHAPTER CONCLUSIONS
1
2
5
Our overall impression is of a maternity unit that felt
itself to be isolated, both geographically and
professionally, and unsupported by the local
healthcare system. This was exacerbated by a series
of health service reorganisations. During this process
there was a loss of ownership and understanding by
local communities; healthcare workers struggled to
deliver safe services when support structures were
changing or disappearing; and, as elsewhere,
financial imperatives dominated all aspects of the
Trust.
Throughout this time there was no agreed vision,
strategy or operational plan for maternity and neonatal
services. Decision-making was reactive rather than
proactive; short term rather than long term; and driven
by finance rather than health needs.
The identification of avoidable factors provided a more
in-depth analysis of clinical practice and service
delivery. There were numerous significant avoidable
factors that were identified during the review process
and which contributed directly or indirectly to the
adverse clinical outcomes, and most of these related
to deficiencies in basic clinical care. There was
evidence of a lack of situation awareness, with a
deficiency in understanding of basic observations,
their clinical significance and how they should be
managed. There were many instances where
symptoms and signs, observations, progress in
labour, and the concerns of patients, parents and
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GAP’s AND ACTIONS
REQUIRED
Maternity provides services in Continue to ensure senior
5 sites as well as across the midwifery and management
community.
presence in each area.
The management structure
has been implemented to
ensure a consistent approach
in all areas. There is a visible
presence in all areas.
OUHT
A draft maternity strategy has Maternity Strategy to
been written.
finalised during 2015/16
be
The senior management and Await outcome of review, for
clinical governance teams are report to Quality Committee in
currently reviewing all recent December 2015.
incidents to identify themes.
A meeting has been arranged
between the senior midwifery
team and Oxford Brookes
University to discuss student
midwife training, mentorship
and post graduate training.
Training and education is
based on local need, learning
from incidents and future
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Oxford University Hospitals
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families were recorded, but were not underpinned by planning i.e. leadership.
a clinical plan or escalation of clinical decision- A number of systems are in
making.
place to mitigate risk i.e.
MEOWs charts, SBAR stickers
and risk stratification at
booking to ensure women are
cared for by the right team.
These systems are audited
regularly.
6
There was evidence of a lack of basic understanding
of the processes of labour by both midwifery and See above.
medical staff. There were frequent examples of staff
ignoring the whole clinical picture of the woman
(including pre-existing risk factors) and her baby, and
only reacting to events in isolation. A lack of clinical
risk assessment and planning for high-risk obstetric
patients was an overarching theme. Despite its
relative isolation, this was most prevalent in FGH.
Clinical risk assessment and effective planning are
crucial if patient harm is to be avoided. Clinical risk
assessment begins with the first contact with the
patient, and this may be at the antenatal clinic, the
clinical assessment unit or the labour suite.
7
Although we did not investigate in detail aspects of There is evidence of multi- None.
hospital care outside the maternity and neonatal unit, professional working within
there was evidence that the response of medical maternity services.
teams from other specialties when complications The service works closely with
developed in pregnant women was inconsistent. staff from a variety of
There was evidence of non-involvement of specialities
including
appropriate multidisciplinary senior clinical staff, a Paediatrics,
cardiology,
lack of escalation and a failure to seek external Obstetric Physicians, Mental
health,
Anaesthetics
and
advice for complex, extremely sick patients.
interventional radiology.
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8
Arrangements for assessing pregnant women who
present with concerns need to ensure that patients
receive an opinion from experienced midwives or
obstetricians. The consultants need to be closer to the
front line, where they can be gatekeepers to their
service and advise and support their junior doctors
and midwifery colleagues. The staffing levels should
ensure that this clinical opinion is available 24/7.
9
The skills and knowledge of the clinicians should
enable a prompt and effective response if the
condition of a mother or her baby deviates from
normal. This may require the patient to be transferred
to a regional unit. A lack of knowledge and experience
is probably responsible for the ‘wait and see’
approach that was prevalent in both the labour suite
and the special care baby unit, and often led to further
deterioration of the patient’s condition and a poor
outcome in the cases we reviewed.
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There is a 24 hour on call
Consultant
Obstetrician
available for support and
advice. At the JR a consultant
is present on the Delivery
suite;
currently 86
hour
presence due to consultant
vacancies.
Budgeted
substantive hours are 107
hours.
Feedback from junior medical
staff and midwives is generally
positive.
A Clinical midwifery manager
and
Consultant
Midwife
responsible for intrapartum
care are available for advice
and support.
Criteria has been agreed to
ensure women receive care
from the appropriate team in
the appropriate unit.
Women are transferred from
the Horton to the JR as
necessary.
The Academic Health Science
Network has produced specific
guidelines
to
ensure
a
consistent and safe approach.
Page 17 of 20
Continually review Consultant
hours. Recruitment is ongoing
to current consultant vacancies
None
Oxford University Hospitals
10
Clinical leadership in maternity and neonatal services
was ineffective. This was partly due to the lack of
vision and strategic planning of these services, but
also due to the lack of managerial support and the
increasingly defiant behaviour by clinical colleagues.
High-quality leadership skills are required in those
difficult circumstances, and these were not evident.
11
Most importantly, there is evidence of poor
interdisciplinary working relations and substandard
care. The failure of obstetricians and paediatricians to
communicate in a professional way on the planning
and delivery of high-risk patients is unacceptable.
Similarly, the reluctance of midwives and obstetricians
to share responsibility for the care of high-risk
pregnant women is denying patients their rights to the
best care.
12
As a consequence of the serial restructuring by the
Trust, maternity and neonatal services had their
management arrangements changed six times during
the period covered by this Investigation. As a result of
this managerial instability, there is evidence that lines
of responsibility and accountability were blurred, many
posts were combined and in some cases became
unworkable, individuals were given management
posts in maternity and neonatal services without any
knowledge or experience of these services, and the
focus was on operational objectives such as finance
and waiting times rather than governance and quality
of service.
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Feedback
suggests
that Continue to monitor and
clinical
and
managerial address any issues as they
leadership
is
generally arise via complaints, and staff
positive.
metrics, as part of regular
divisional reporting
There is evidence of positive None
interdisciplinary
working
relations between staff and
departments
across
the
organisations.
There is evidence of positive
working relationships between
the
obstetricians
and
midwives.
There has not been any None
restructure within the service
for a number of years.
A rigorous recruitment process
is in place and Trust policies
are always adhered to.
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Oxford University Hospitals
13
The clinical review has identified deficiencies at all
levels within the organisation that impact on quality of
clinical care: clinicians who place their personal
clinical interest before the safety of their patients;
failure of the FGH and RLI clinicians to work as an
effective clinical team; weak clinical leadership and
poor management at the directorate and division
levels; and an executive team that was more focused
on obtaining Foundation Trust status than on
delivering high-quality care to the citizens of South
Cumbria and North Lancashire.
14
Finally, at interview, patients, parents and families
indicated that they had not received adequate – or in
some cases any – explanations of why something
went wrong, and indeed still had basic questions
about aspects of the care received. This has led to
assumptions of a cover-up of poor care and has
exacerbated their feelings of grief and loss. In
addition, the Trust needs to reflect on how it managed
the serious incidents, especially when the media and
external agencies became involved. Many of the
clinical staff wished they could have spoken directly
with the families to apologise and express their
deepest sympathies. They also felt that they had not
had an opportunity to fully explain what they felt were
the failings in the care that the patients received.
Many still feel devastated and damaged by what
happened. The Trust recognises that it has to rebuild
trust and confidence in the service and in the
community, and part of that process should be to
consider what the Trust can do to repair the emotional
damage experienced by its staff and the family
members of its patients.
TB2015.86 Kirkup Report 2015, Gap Analysis, Maternity Services
TB2015.86
This would not be tolerated None
within the service; team
working is embedded in the
culture
of
the
maternity
service.
Incident reporting in maternity
services is embedded and staff
are aware of when/how to
report incidents. Investigations
are completed in line with Trust
and National standards.
Reporting is through the
Women’s Clinical Governance
Committee and to Trust Risk
Management.
Feedback is provided to the
family along with a copy of the
report.
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Oxford University Hospitals
3.
Chapter Four: Trust response
NUMBER
CHAPTER CONCLUSIONS
3
We believe that a combination of poor clinical skills
and knowledge, lack of engagement, lack of
ownership of problems, and failure to escalate
concerns amongst maternity staff led to problems not
being evident at Trust level. Governance systems
were not sensitive enough to identify this problem in
the absence of other indicators of poor outcome prior
to 2008.
Had the clinical problems been escalated effectively
to more senior level prior to 2008, it is possible that
effective corrective action could have been taken
before the dysfunctional nature of the unit that we
have described elsewhere became embedded and
more widespread.
4
10
The failure to follow up formally the findings of either
the Flynn or the Fielding review at the level of the
Trust Board, or to continue to progress the original
aim of exploring the acknowledged problems in
obstetrics, once the external pressure had gone away,
was a failure of clinical and corporate governance.
TB2015.86 Kirkup Report 2015, Gap Analysis, Maternity Services
TB2015.86
GAP’s AND ACTIONS
REQUIRED
Concerns are reported and None
escalated using the Trust’s
incident reporting structure.
The Directorate and Divisional
structures are used to highlight
any areas of concern and then
escalated to the Executive
team as appropriate.
The maternity services are not As part of the development of
dysfunctional.
The senior the Maternity Strategy, current
clinical
and
managerial processes and structure will be
structures, as well as robust, reviewed by the end of
evidence based guidelines 2015/16.
promote good practice.
Auditing processes of clinical
Audits of national standards practice continue to be refined
are in place which will identify
any
gaps
or
training
requirements.
Local or national reviews of None
maternity
services
are
discussed at Directorate and
Divisional level and escalated
to Trust Board.
GAP ANALYSIS
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