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
An independent review of serious untoward incidents and clinical governance systems within maternity services at Northwick Park Hospital (16 September 2008)
https://moderngov.harrow.gov.uk/documents/s30776/Maternity%20Review%20Report.pdf
0
reactions so far
0 Comments
Recommended Comments
There are no comments to display.
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now