News: A&A review

A Review concludes that Ayrshire Maternity Unit’s
adverse events processes not robust

Increased training and better family engagement also required

An independent review of the management of adverse events at Ayrshire Maternity Unit, University Hospital Crosshouse, NHS Ayrshire & Arran, has concluded that processes to investigate adverse incidents need to be more robust to ensure that learning is maximised.

The report published today (Tuesday) by Healthcare Improvement Scotland, also recommends that increased training for staff and protected time to investigate adverse events will further increase safety.

In producing the report, the review team spoke to a number of families about their experiences of Ayrshire Maternity Unit and the report recommends that communication with families who have experienced bereavement or complications during birth need to be improved.

In all, the report makes eight recommendations to increase safety and the management of adverse events.

The report was also informed by the findings of a separate clinical case review report on the circumstances of individual perinatal deaths within the Ayrshire Maternity Unit. The findings of the clinical case reviews will be discussed with the individual families by NHS Ayrshire & Arran.

Key findings

  • The NHS Ayrshire & Arran Significant Adverse Event Review (SAER) process was not used for significant adverse events in the maternity unit. The maternity unit circumvented deficiencies in the NHS board’s adverse event management policy in order to maximise local clinical engagement in reviews. The review team believes that this is indicative of the need to strengthen the wider organisational adverse event process.
  • NHS Ayrshire & Arran has carried out a very small number of SAERs using its established and published process.
  • Once the event has been initially reported, there was uncertainty amongst maternity unit staff regarding the appropriate process to follow in response to an adverse event.
  • The adverse event documentation, within the initial assessment process, is not consistently completed and fails to provide clear rationale for deciding the level of adverse event review required. 
  • Continual education and local training programmes for staff should be used as a mechanism to share and embed learning from adverse event reviews, allowing real-time implementation of improvements in practice.
  • There is low uptake of important training and development specifically for maternity unit staff.

Key recommendations

  • The NHS board must strengthen its current adverse event management policy to make sure it adheres to the National Framework and provides useful and practical processes that can be quickly and simply followed.
  • NHS Ayrshire & Arran must improve family engagement and make sure that families are provided with appropriate information, support and opportunities to enable them to be involved in any significant adverse event process.
  • NHS Ayrshire & Arran staff must be adequately supported to be involved in the management of adverse events across the maternity unit.

Speaking of the report, Dr Tracey Johnston, Chair of the independent review group and Consultant Obstetrician at Birmingham Women’s and Children’s NHS Foundation Trust, said:

“In preparing this report, we heard from families devastated by the death of their baby around the time of birth, and I thank them for having the strength to come and talk to us. Their narratives gave us insights we otherwise would not have had and strengthened the review by enabling us to explore specific areas with the staff at Ayrshire Maternity Unit. This report, combined with the clinical case review, provides a full picture of care in this unit.

“We found the team at Ayrshire Maternity Unit to be a cohesive and highly motivated team with strong leadership, committed to providing high quality care to those they look after. We saw some examples of good use of learning and improvement.

“However, there are clearly lessons to be learned from this review, not just for NHS Ayrshire & Arran but for Scotland as a whole.  These lessons, through the recommendations of this report, should be embraced as ways to learn from such serious cases and improve care across NHS services.”

Robbie Pearson, Chief Executive of Healthcare Improvement Scotland, said:

“This was a thorough review and I am grateful to the work of the review group.  It’s clear that more still needs to be done on handling serious adverse events effectively and sensitively, in particular with the families concerned. We will continue to closely monitor NHS Ayrshire & Arran and to work with them to ensure that they maximise opportunities to learn from adverse events and reduce avoidable harm wherever possible.”

More information

Published date: 27 June 2017