An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital (16 September 2008)

Summary

This report presents the findings and conclusions of an independent review into clinical governance arrangements within maternity services at The North West London Hospitals NHS Trust. The independent review was set up following three maternal deaths in one year and two other serious untoward incidents (SUIs) in the Trusts's maternity unit.

Content

Key findings

• The maternal deaths and incidents were not the result of deficiencies of care.
• Standards of care when a woman is admitted to the delivery suite are well above average.
• Incident reporting and investigation systems are of a high quality.
• There are examples of excellent practice which should be widely disseminated.
• Governance systems are fit for purpose and generally well applied.

Recommendations

The review panel made the following essential recommendations to further reduce risks for the large proportion of vulnerable and high risk women attending the unit:

• Better delivery of antenatal care in the community by an expanded team of community midwives, ensuring that all women have equitable standards of antenatal care including appropriate access to obstetric and midwifery services, particularly those most vulnerable.
• Optimising antenatal care of high risk women by applying best practice guidelines (including monitoring the effectiveness of the ‘did not attend’ policy) and implementing recommendations of the National Institute for Health and Clinical Excellence (NICE) guidelines 2006 for the care of women in the postnatal period, strengthening leadership skills and inter-professional and inter-specialty communication.
• Providing better opportunities for multidisciplinary learning from incidents.
• Reviewing assurance processes in the governance framework.

Related reading

Investigation into 10 maternal deaths at, or following delivery at, Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005 (August 2006)