Maternal and Neonatal Safety Improvement Programme and the Ockenden Reports

Maternity services and midwifery are working through difficult and challenging times. The continued staffing crisis and covid pandemic pressures along with the investigating lens on services is resulting in high level burn out. The effects of the pandemic on the workforce have highlighted the need for a spring clean of culture within our services at every level. The heart of improvement work is to improve the safety outcomes for women, pregnant people, babies, and their families while ensuring an open and supportive work culture.

There have been several maternity reports over recent years with the two most recent being the Ockenden reports (2020, 2022). These reports from Shrewsbury and Telford Hospital Trust have had significant and lasting impact on maternity services. This publication of the Ockenden reports along with the pending Kirkup review enhances the need for collaboration. The promise to learn and act, requires the need to share improvement plans to create a compassionate, supportive, and continually learning workforce.

The MatNeo programme is part of the patient safety collaborative (PSC) and has three key areas of work for this current year. Optimisation of the preterm infant, early detection of deterioration of the mother and neonate, and culture. Here in Wessex our aim is to improve engagement between organisations, service users and the implications considering the Ockenden requirements.

The term culture be it organisational, team or safety has been around for a long time. Each region and trust will be provided the opportunity to partake in an updated SCORE survey, to better understand their organisational culture. We are working to support team culture further with an innovative team coaching programme to wrap around the optimisation teams. The Wessex MatneoSIP leads are working closely with our IOW and Southampton Maternity Voice Partners - Emma Batt and Lynsey Stanton are supporting various work streams, particularly around culture.

Regional Teams are currently visiting every Trust for the first of their annual insight visits support the planning and implementation of the immediate essential actions from the first Ockenden report. These visits will assess the outputs of the self-assessment and will work with providers to understand where the gaps are and provide additional support where needed. This will ensure the immediate and essential actions (IEAs) are implemented with the pace and rigour commensurate with the findings to ensure mothers and their babies are safe.

The key themes from the report:

• Patterns of repeated poor care with limited learning and improvement.
• Failures in governance and leadership (both internally and externally).
• Issues with identification of risk, appropriate escalation, and delays in care.
• Significant safety culture issues. 
• Poor communication and a lack of compassion experienced by women and families.
• Lower than average caesarean section rate and the culture that supported this.

The MatNeo programme sits across several of the key drivers for maternity services. The three workstreams can be clearly identified within these key themes and the specific IEAs below:

Optimisation

• The review endorses the recommendations from the Neonatal Critical Care Review.
• The LMNS (Local Maternity and Neonatal Systems), commissioners and trusts must work collaboratively to ensure systems are in place for the management of women at risk of preterm birth.
• There must be a continuous audit process to review all in-utero transfers and cases where a decision is made not to transfer to a Level 3 neonatal unit and, when delivery subsequently occurs, in the local unit.
• Maternity and neonatal services must continue to work towards a position of at least 85% of births at less than 27 weeks' gestation taking place at a maternity unit with an onsite NICU (Neonatal Intensive Care Unit).
• Saving Babies Lives 2 must be implemented – which includes preterm optimisation. MatNeo takes the optimisation further improving potential outcomes for preterm babies’ long-term wellbeing. 

Governance

• Every trust must ensure they have a patient safety specialist who is specifically dedicated to maternity services
• All maternity service senior leadership teams must use appreciative inquiry to complete the National Maternity Self-Assessment Tool if not previously done. 
• Trust boards must work together with maternity departments to develop regular progress and exception reports, assurance reviews and regularly review the progress of any maternity improvement and transformation plans. All trusts must ensure that those individuals leading maternity governance teams are trained in human factors, causal analysis, and family engagement.
• NHS England has published the new Patient Safety Incident Response Framework (PSIRF) outlining how NHS organisations should respond to patient safety incidents for the purpose of learning and improvement. The framework will replace the current Serious Incident Response Framework by Autumn 2023. This represents a significant shift in the way the NHS responds to patient safety incidents, centring on compassion and involving those affected; system-based approaches to learning and improvement; considered and proportionate responses; and supportive oversight. PSIRF is a major step towards improving safety management across the healthcare system in England and will support the NHS to embed the key principles of a patient safety culture. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals; allowing for more effective learning and improvement and making NHS care safer for patients

Escalation

• Staff must be able to escalate concerns 
• Multidisciplinary training must integrate the local handover tools such as SBAR (Situation-Background-Assessment-Recommendation) into teaching programmes at all trusts.
• All trusts must develop and maintain a conflict of clinical opinion policy to support staff members in being able to escalate their clinical concerns regarding a woman’s care in case of disagreement between health care professionals

What are we doing locally in Wessex? 

We work closely with the Operational Delivery Networks, Maternity Transformation Programme teams and LMNSs across the region and with our neighbouring Southwest and Southeast areas to support the development of systems. We work with teams in each of the Trusts to support the development and implantation of quality improvement projects within the deterioration and optimisation spaces. Preparation for the national implementation of MEWS (Maternity Early Warning Score) and NEWTT2 (Newborn Early Warning Trigger and Track) in our fully digital region.

Wessex started its optimisation work in the last year and have made some amazing forward movements in optimal cord clamping whilst working to continue the progress in other areas such as magnesium sulphate and normothermia. Our right place of birth for preterm infants is currently the best in the country demonstrating the fantastic region wide communication and working culture to supporting these families.

The Wessex Antenatal Care Pathways (WACP) are a regionally designed pack of 19 agreed guideline care pathways to support community midwives, GP’s, triage lines and day assessment areas. They have been reviewed by a multi professional faculty in line with evidenced based and best practice. These pathways support early recognitions of deterioration in the pregnant women or person and baby. The yearlong review process completed in August 2022 and the new versions will be available for health professionals and service users this autumn via each Trust, The Wessex Academy and Wessex Healthier Together app. We are holding a pathway learn and share event so keep your eyes peeled for further communications. 

If you have any questions about the work that MatNeo does or would like to get involved in your area don’t hesitate to contact Rebecca Savage (optimisation and culture) or Alison Scannell (deterioration and PSIRF) via the contact us page. Alternatively, you can view more of the work we do on our webpage.