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Agenda Item 4.3(i)

4.3 Maternity Service NHS Resolution Scheme - QAC 4 July 2019

THE LEEDS TEACHING HOSPITALS NHS TRUST

QUALITY ASSURANCE COMMITTEE

4TH JULY 2019

Clinical Negligence Scheme for Trusts (CNST) Incentive Scheme (Maternity Safety Actions): Assurance and Recommendation for

Trust Board Sign Off

1. PURPOSE This paper presents the summary of the Trust’s compliance with the CNST Incentive Scheme (Maternity Safety Actions) 2019/20. Compliance must be reviewed by the Trust Board / Local Maternity Commissioners, and endorsed before the signed declaration form (Appendix 2) is submitted to NHS Resolution (previously NHSLA) in August 2019. NHS Resolution (NHSR) will subsequently contact the Neonatal & Maternity Operational Delivery Network (ODN), NHS Digital and local Maternity system to validate certain criteria. A meeting has been arranged for 1/07/19 with the maternity commissioners to endorse the evidence. When appropriately assured a representative of the Trust Board must sign off the NHS Resolution Board declaration included in Appendix 2. The purpose of this paper is to provide that assurance and recommend Trust Board sign off. 2. BACKGROUND The Incentive Scheme for 2019/20 is the second year LTHT Maternity Services has collated and submitted evidence to NHS Resolution. In 2018/19 full compliance was achieved across all 10 elements. The Incentive Scheme comprises 10 safety actions, each with multiple evidence requirements. Trusts must be compliant with all 10 elements in order to achieve the incentive saving. NHS Resolution reserves the right to award no incentive saving to Trusts achieving less than the full 10 elements. The 10 safety actions are:

1. Are you using the National Perinatal Mortality Review Tool (NPMRT) to review perinatal deaths to the required standard?

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Text Box

Blue Box Agenda item 10.1(v) Appendix 1

Agenda Item 4.3(i)


2. Are you submitting data to the Maternity Services Data Set (MSDS) to the required standard?

3. Can you demonstrate that you have transitional care services to support the Avoiding Term Admissions into Neonatal Units Programme?

4. Can you demonstrate an effective system of medical workforce planning to the required standard?

5. Can you demonstrate an effective system of midwifery workforce planning to the required standard?

6. Can you demonstrate compliance with all 4 elements of the Saving Babies' Lives (SBL) care bundle?

7. Can you demonstrate that you have a patient feedback mechanism for maternity services, such as the Maternity Voices Partnership Forum, and that you regularly act on feedback?

8. Can you evidence that 90% of each maternity unit staff group have attended an 'in-house' multi-professional maternity emergencies training session within the last training year?

9. Can you demonstrate that the trust safety champions (obstetrician and midwife) are meeting bi-monthly with Board level champions to escalate locally identified issues?

10. Have you reported 100% of qualifying 2018 /19 incidents under NHS Resolution's Early Notification scheme?

The NHS Resolution mandate a template for evidence submission, this is included at Appendix 1. 3. ASSESSMENT The Trust has collated evidence and of the 10 criteria 10 are fully assured and evidence can be provided (see Appendix 1). 4. RECOMMENDATIONS

1. It is recommended that QAC endorse this evidence summary and recommend review and endorsement by the Trust Board

Susan Gibson Head of Nursing and Midwifery Women’s Clinical Service Unit Appendices Appendix 1 Detailed standards and NHS Resolution Evidence Summary Template Appendix 2 NHS Resolution Board Sign Off Template


Appendix 1 - Detailed Standards and NHS Resolution Evidence Summary Template

Board report on Leeds Teaching Trust progress against the Clinical Negligence Scheme for

Trusts (CNST) incentive scheme maternity safety actions year 2

Date: 25/06/19

SECTION A: Evidence of Trust’s progress against 10 safety actions:

Please note that trusts with multiple sites will need to provide evidence of each individual site’s performance against the

required standard.

Leeds Teaching Hospitals NHS Trust has two acute maternity sites, Leeds General Infirmary (LGI) and St James’s University

Hospital (SJUH). The services are identical, sit under the same clinical management team, use the same guidelines, and submit all

audit data and national requirements etc together. Workforce moves across both sites and so the teams are closely integrated.

Because of the NHS Resolution requirement to report per site, the ‘action met’ column has therefore been split into two sections,

one for LGI and one for SJUH. Where evidence is collated per site (for example RCOG workforce audit) this is provided in two

parts, one for each site and marked as such. Where evidence is produced and collated as a whole service (for example NHS

Resolution submissions or MSDS data submission) the evidence is provided for both sites included one evidence submission,

however the ‘action met’ column clearly denotes compliance for each site, for the avoidance of doubt.


Safety action

– please see

the guidance

for the detail

required for

each action

Evidence of Trust’s progress Action met? (Y/N)

1). Are you

using the

National

Perinatal

Mortality

Review Tool

(NPMRT) to

review

perinatal

deaths to the

required

standard?

Required Standard:

a) A review of 95% of all deaths of babies suitable for review using the Perinatal Mortality Review Tool (PMRT) occurring from Wednesday 12 December 2018 have been started within four months of each death. b) At least 50% of all deaths of babies who were born and died in your trust (including any home births where the baby died) from Wednesday 12 December 2018 will have been reviewed, by a multidisciplinary review team, with each review completed to the point that a draft report has been generated, within four months of each death. c) In 95% of all deaths of babies who were born and died in your trust (including any home births where the baby died) from Wednesday 12 December 2018, the parents were told that a review of their baby’s death will take place and that their perspective and any concerns about their care and that of their baby have been sought. d) Quarterly reports have been submitted to the trust Board that include details of all deaths reviewed and consequent action plans.

SJUH - YES

LGI - YES


Trust comment:

Following the launch of the tool in 2018 Maternity services can demonstrate the

application of the MBRRACE perinatal mortality review tool on all of the above required

evidence. This requirement is reflected in a database which identifies for 2019 - 20 :

All neonatal deaths

All stillbirths

Late loss 22 -23 weeks

Intrauterine deaths of twins < 24 weeks

Cases not for review

Additionally the data base includes:

Date of MDT review

Identification of completion of either in 4/12 or not

Grading of care

Parents informed of PMRT / MDT review and feedback

The date the parents are given feedback

Parental questions

Date the reports are shared with the Trust Board via the Safety Outcome Group

Actions added to the action tracker

Themes / issues in care

Themes of good practice


Evidence:

1.1 Database 2019 - 20 - confirming 100% PMRT has been completed within 4 months

and 100% of parents are informed of the PMRT/ MDT review and feedback

1.2 PMRT Audit tool reviews

1.3 Standard Operating Procedure (SOP) for perinatal mortality review

1.4 Perinatal mortality review meeting minutes

1.5 Safety Outcome Sub Group minutes including Maternity Risk section details quarterly

reporting for Perinatal Mortality including timely completion of PMRT.

1.6 All cases have had PMRT completed within 4 months as required. There is 1 case

that is currently part of a Health Safety Investigation Board (HSIB) investigation

which does not meet the timeframe - however HSIB and NHS Resolution have

agreed that these cases are exempt, and the PMRT tool to be completed once a

report is received from HSIB.

2). Are you

submitting

data to the

Maternity

Services Data

Set (MSDS) to

the required

standard?

Required Standard:

NHS Digital will issue a monthly scorecard to data submitters (trusts) that can be presented to the Board. The scorecard will be used by NHS Digital to assess whether each MSDS data quality

criteria has been met and whether the overall score is enough to pass the assessment. It

is necessary to pass all three mandatory criteria and 14 of the 19 other criteria (please

see table below for details).

SJUH LGI


Trust Comment:

NHS Digital issue a monthly scorecard to trusts following data submission, 14 out of 19

criteria are required to pass - LTHT are achieving this requirement from January 2019 to

present.

20/06/19 - The maternity service has been notified from NHS Digital of the successful

submission of April data in June 2019, and have confirmed that all 3 mandatory criteria

with at least 14/19 of the optional criteria has been passed.

Evidence:

Mandatory requirements as follows have all been met:

1.1 January 2019 data contained at least 90% of HES birth expectation based on

number of days in month

1.2 MSDS v2 questionnaire completed and returned to NHS Digital within time scale

required - email on 21/02/19 confirms the completion and receipt of the

questionnaire by NHS Digital

1.3 Submission of MSDS v 2 data for April 2019 by the end of June 2019

A minimum of 14 of the optional 19 categories have been achieved


3). Can you

demonstrate

that you have

transitional

care services

to support the

Avoiding

Term

Admissions

into Neonatal

units

programme?

Required Standard:

a) Pathways of care for admission into and out of transitional care have been jointly approved by maternity and neonatal teams with neonatal involvement in decision making and planning care for all babies in transitional care. b) A data recording process for transitional care is established, in order to produce commissioner returns for Healthcare Resource Groups (HRG) 4/XA04 activity as per Neonatal Critical Care Minimum Data Set (NCCMDS) version 2. c) An action plan has been agreed at Board level and with your Local Maternity Systems (LMS) and Operational Delivery Network (ODN) to address local findings from Avoiding Term Admissions Into Neonatal units (ATAIN) reviews. d) Progress with the agreed action plans has been shared with your Board and your LMS & ODN

SJUH - YES LGI - YES

Trust comment: Maternity services can demonstrate that transitional care facilities are in place on both sites in the city managed by the Children’s CSU. The St James site has 13 cots and the Leeds General Infirmary has 6 cots. Both units are staffed with midwives and neonatal nurses supporting the added provision for the transitional care baby. There are universal guidelines relating to postnatal and transitional care which are operational in both units and there is current focus to support the implementation of the ATAIN Programme with input from the neonatal and postnatal medical / midwifery and nursing staff. The multidisciplinary teams are meeting to take forward elements of the ATAIN programme which have been allocated to the neonatal consultant leads.


Evidence: Example of pathway of care - Criteria for Admission to the Transitional Care Unit / New Criteria for babies Admitted to the Post Natal wards The patient administration system - BADGERNET - in both SCBU/ NNU at SJUH/ LGI collect and record the HRG returns for transitional care Email acknowledging receipt of LMS/ ODN ATAIN Action Plan 18/4/19 confirming receipt of the initial ATAIN Action plan by 10/3/19 ATAIN Action Plan version 1 presented at SOSG Feb 2019 - minutes confirm ATAIN Action Plan version 2 presented at SOSG June 2019 - minutes to confirm LMS Board meeting minutes for receiving ATAIN Action Plan version 1 17/5/19 Staffing Model Paper for Transitional Care - Paper presented 20/06/19 - SOSG agreed and signed by Maternity and Neonatal Clinical leads

4). Can you

demonstrate

an effective

system of

medical

workforce

planning to

the required

standard?

Required Standard:

a) Formal record of the proportion of obstetrics and gynaecology trainees in the trust who ‘disagreed/strongly disagreed’ with the 2018 General Medical Council National Training Survey question: ‘In my current post, educational/training opportunities are rarely lost due to gaps in the rota.’ In addition, a plan produced by the trust to address lost educational opportunities due to rota gaps. b) An action plan is in place and agreed at Board level to meet Anaesthesia Clinical Services Accreditation (ACSA) standards 1.2.4.6, 2.6.5.1 and 2.6.5.6.



Trust comment:

Trainees to Obs & Gynae (time period 20/3 - 9/5/18) who responded to the GMC Survey were 65.6% overall satisfied with training opportunities, 1/3rd were either dissatisfied or very dissatisfied ; a review with the college tutors has resulted in an action plan to address those concerns. A copy of the paper and action plan emailed to the RCOG post discussion at SOSG June 2019. SBAR on the current status on the provision of Elective LSCS lists for LTHT (time period Jan - June 201)) which confirms for planned Elective LSCS lists there are dedicated obstetric, anaesthesia, theatre and midwifery staff are present . A separate anaesthetist is allocated for elective obstetric work and on ward rounds an anaesthetist is present and this is recorded in the K2 (maternity patient administration system) record for each woman seen

Evidence:

A) Paper Effective System of Medical Workforce (GMC Survey) presented to Safety

Outcome Group 20/6/19 - minutes to follow

B) Copy of above has been emailed to the RCOG following presentation at SOSG in

June 2019

C) Paper Effective System of Medical Workforce ( Elective LSCS) presented to

Safety Outcome Group 20/6/19 - minutes to follow

D) Records of women undertaking Elective LSCS are available with documentation

of the daily ward rounds recording the MDT including duty anaesthetist

participating in the ward round and any subsequent requests/ actions requested.


5). Can you

demonstrate

an effective

system of

midwifery

workforce

planning to

the required

standard?

Required Standard:

a) A systematic, evidence-based process to calculate midwifery staffing establishment has been done. b) The obstetric unit midwifery labour ward coordinator has supernumerary status (defined as having no caseload of their own during that shift) to enable oversight of all birth activity in the service c) Women receive one-to-one care in labour (this is the minimum standard that Birthrate+ is based on) d) A bi-annual report that covers staffing/safety issues is submitted to the Board



Trust comment:

The Trust has provided evidence of a systematic, evidence-based process to calculate

midwifery staffing establishment, summarised in the Midwifery Workforce Review paper,

which includes neonatal nursing, as good practice. The evidence used for the review

was the midwifery staffing establishment for January to March 2019 (quarter 4), as the

required timeframe by the NHS Resolution standards.

The current service model and care pathways are responsive to the changing needs of women, babies and their family. With the number of births exceeding 9,551, the key drivers for LTHT have been to:

Provide “one to one” care in labour as advised in Towards Safer Childbirth

Ensure the sustainability of midwifery and support worker staffing for the future including succession planning

Review the skill mix

Reduce litigation

Reduce complaints

Continue to be the hospital of choice for the women of Leeds and the surrounding geographical area

Safer Childbirth (2007) indicates that to support one-to-one care in delivery the minimum

midwife-to-woman ratio is 1:28. In areas with a more complex case mix then this ratio

may need to be lower. Our caseload mix demonstrates that approximately 44% of

women delivered in Leeds fall into categories IV and V.

Our Midwife to birth ratio is currently lower than the required standard (good) at 1:26.


Evidence:

5.1 Midwifery Workforce Review of Staffing including Neonatal Nursing (paper for CSU

Governance and Safety Outcome Group June 2019).

5.2 Hard truths data for maternity presented to Trust Board - Planned v actual midwifery

and non- qualified staffing

5.4 Current Midwife to Birth ration = 1:26

5.5. 5.3 Trust Policy demonstrating that, as standard, midwifery labour ward shifts are

rostered in a way that allows the labour ward coordinator to have supernumerary status

(defined as having no case load of their own during that shift). There are two policies

with this requirement and both have been included:

Maternity Services Escalation Policy & Maternity Services Risk Management policy

The Midwifery Workforce review demonstrates 100% compliance with supernumerary

labour ward status and the provision of one to one care in active labour dashboard

5.6 The percentage of specialist midwives employed including management is detailed

within the Review of Staffing report (quarter 4) paper detailed above

5.6 The Trust uses the Birthrate plus tool to monitor staffing and acuity and inform

workforce planning. Exemplars from both sites from the period January-March 2019 are

included as evidence:

5.7.1 SJUH Birthrate Plus charts

5.7.2 LGI Birthrate Plus charts

5.8 Details of red flag events are covered in quarter 4 Midwifery Workforce Review of


Staffing paper.


6). Can you

demonstrate

compliance

with all 4

elements of

the Saving

Babies' Lives

(SBL) care

bundle?

Required Standard:

Board level consideration of the Saving Babies' Lives (SBL) care bundle (Version 1 published 21 March 2016) in a way that supports the delivery of safer maternity services. Each element of the SBL care bundle implemented or an alternative intervention in place to deliver against element(s).


Trust comment:

Maternity services can demonstrate compliance with all 4 elements of the Saving Babies’ Lives (SBL) version 1 care bundle and this is reflected on the March 2019 Yorkshire & Humber - Saving Babies’ Lives survey (no:12) with full compliance against the 4 elements achieved from survey 9 - Dec 2017 to March 2018. LTHT maternity services have been fully involved in the SBL care bundle and regional SABINE work, and the development of Saving Babies Lives version 2 launched March 2019.


Evidence:

1 Smoking

Standard: Outcome indicators - Number/rates of women smoking at booking

6.1 Smoking at booking rates

6.2 Smoking in Pregnancy Action Plan which includes CO monitoring and an ‘opt out’

pathway for smoking cessation services

2 Fetal growth restriction

Standard: Ongoing audit, reporting and publishing (on local dashboard or similar) of

Small for Gestational Age (SGA) birth rate, antenatal detection rate, false positive rate

and false negative rate.

6.3 Audit and Reporting of SGA birth rate, detection rate, false positive and negative rate

6.4 Dashboard (publishing) on SGA birth rate, detection rate

6.5 Assessment and Management Algorithm compliant with RCOG Green Top No.31

Standard: Ongoing case-note audit of selected cases not detected antenatally, to identify

learning and improve future detection

6.6 Audit of cases not detected antenatally to identify learning.

6.7 Summary of learning from audit of compliance with guidelines for SGA

3 Reduced fetal movement

Standard: Use provided checklist to manage care of pregnant women who report


reduced fetal movement, in line with RCOG Green-top Guideline 5717

6.8 Reduced Fetal Movement Checklist which is compliant with RCOG Green-Top

Guideline

6.9 Leaflet for Women - this is discussed at 24 weeks as part of the pathway and

reduced fetal movements are discussed at all subsequent contacts

4 Effective fetal monitoring during labour

Table detailing compliance rate for staff who have undertaken the required CTG

training and competency package in the last 12 months in line with the CSU Training

Needs Analysis .

Staff group Number of staff trained and competence assessed in last 12 months

Compliance %

Midwives 256 100%

Trainees 34 100%

Consultants 20 100%

6.13 A buddy system is used in Leeds for reviewing CTGs and there is an escalation process in place for concerns. The escalation process is included as evidence.


7). Can you

demonstrate

that you have

a patient

feedback

mechanism

for maternity

services,

such as the

Maternity

Voices

Partnership

Forum, and

that you

regularly act

on feedback?

Required Standard:

Evidence should include: Acting on feedback from, for example a Maternity Voices Partnership. User involvement in investigations, local and or Care Quality Commission (CQC) survey results. Minutes of regular Maternity Voices Partnership and/or other meetings demonstrating

explicitly how a range of feedback is obtained, the action taken and the communications

to report this back to women.



Trust comment:

We encourage feedback on our services and care provided through a number of routes including Friends & Family Test (FFT), Patient Advice Liaison Service (PALS) and Maternity Voices Partnership (MVP), Walk the patch, 15 Steps, 1 to 1 meetings between HOM & Leeds MVP Chair, LMS MVP Chair, Maternity Network and Feedback directly to team leaders. Leeds MVP is commissioned by Leeds CCG and is currently co-ordinated by Women’s Health Matters, a third sector organisation who employ the Chair of the MVP. Leeds MVP meets quarterly to hear feedback from families and to discuss maternity service successes, opportunities and challenges (minutes available). Prior to this meeting the lay MVP members meet to discuss issues and collate any themes. Subgroups to the MVP:

Homebirth

Bereavement

PMH & Emotional wellbeing

Young Parents Pathway (Mindwell - CCG)

Leeds dads In addition to the main meeting, MVP members attend one of our sites on a monthly basis and use the ‘Walk the Patch ‘approach visiting a clinical area talking to service users, with immediate feedback to a team of senior midwives. 15 Steps for Maternity Toolkit piloted in Leeds to observe our service provision and listen to women and their families on the wards.


Evidence:

7.1 Evidence of collaborative engagement events

7.2 Minutes of MVP / Academic/ CCG / NHS Public Health / Maternity Strategy and

Specification / City of Sanctuary & Haamla Team / Practice Education Team meetings

7.3 Evidence of engagement and involvement of women and families in producing

patient information - IOL / Perineal Tears / My Journey

7.5 Feedback from a ‘walking the patch’ MVP event - Team Leaders Minutes

7.6 Evidence of engaging ‘hard to reach’ groups or groups with particular needs

(Learning disabilities engagement report) - Learning Disability / Haamlaa meeting

minutes

7.7 Antenatal Information

7.8 Parent craft Room notice boards

7.9 CQC Picker Maternity survey Jan 2019 - most improved maternity unit and overall

first

7.10 K2 Pre consultation survey

7.11 Mother on Line maternity records - focus group

7.12 Breast feeding plan

7.13 Group Ante Natal Consultations

7.14 Continuity of carer consultations and involvement


7.15 Maternity / Neonatal Safety collaborative Presentation in London March 2019 -

HOM & Leeds MVP Chair joint presentation re Involving women with Quality

improvement

7.16 Service users participating in the appointment of senior midwives as a part of the

interview panel

7.17 Leeds MVP / HOM presentation at York In March 2019 re co design / co working

7.18 LTHT Patient experience Group presentation from Maternity joint presentation by

Deputy Leeds MVP chair and Maternity representatives


8). Can you

evidence that

90% of each

maternity unit

staff group

have attended

an 'in-house'

multi-

professional

maternity

emergencies

training

session

within the last

training year?

Required Standard:

90% of each maternity unit staff group have attended an 'in-house' multi-professional maternity emergencies training session within the last training year.


Trust comment: The maternity services Training Needs Analysis covers all maternity unit staff groups and requires maternity unit staff to attend an in-house multi- professional maternity emergencies training session each year. This training course is ‘YMET’ and consists of a full day and a half day scenario based training session on clinical management for a range of maternity emergencies. This approach is alternated annually. MOET is also included for the anaesthetists. Scenarios are informed by clinical guidelines. As per the evidence below in the last 12 months (data produced in June 2019 ) over 90% of staff in each staff group have completed their maternity emergencies training

Evidence:

Staff group Number of staff eligible for training

Number of staff trained and competence assessed in last 12 months

Compliance %

Midwives 386 350 90.6%

Midwifery Support Workers

87 79 90.75%

Trainees 40 38 95%

Consultant obstetricians

21 19 90.4%

Consultant anaesthetists

16 15 93.75%


9). Can you

demonstrate

that the trust

safety

champions

(obstetrician

and midwife)

are meeting

bi-monthly

with Board

level

champions to

escalate

locally

identified

issues?

Required Standard:

a) The Executive Sponsor for the Maternal and Neonatal Health Safety Collaborative (MNHSC) is actively engaging with supporting quality and safety improvement activity within:

i. the Trust ii. the Local Learning System (LLS) b) The Board Level Safety Champions have implemented a monthly feedback session for maternity and neonatal staff to raise concerns relating to relevant safety issues c) The Board Level Safety Champions have taken steps to address named safety concerns and that progress with auctioning these are visible to staff


Trust comment: Named Trust Safety Champions are Dr Yvette Oade (Medical Director), Sue Gibson (Head of Nursing and Midwifery) and Dr Kelly Cohen (Clinical Director). Maternity services can demonstrate that the Trust Executive Sponsor for the Maternal & Neonatal Health Safety Collaborative - Dr Yvette Oade actively supports quality and safety improvement activity within the Trust and encourages the maternity services involvement in the wider Local Learning System i.e. PEACHES / OASI QI Project / A-EQUIP midwifery supervision model/ ATAIN QI Workstreams / PreCEPT QI workstream / Baby Friendly Initiative The CSU Safety champions (obstetrician and midwife) are meeting bi-monthly with


board level champions to escalate locally identified issues via a safety outcomes sub group (SOSG) forum report. The Trust work plan for the SOSG forum has been updated to reflect the required bi-monthly reporting by maternity. The Board level safety champions have implemented a monthly feedback session for maternity and neonatal staff to raise concerns relating to relevant safety issues via anonymous feedback Safety Boxes in all clinical areas which feed into the Safety Outcome Meeting Maternity risk paper. A ‘You said. We Did ‘Board is all clinical areas demonstrating improvements taken directly in response to staff using Safety Boxes in all areas. This is updated on a monthly basis. Feedback is also disseminated through the monthly CSU newsletter. A Clinical Leadership fellow to commence August 2019 for improving quality in the maternity services sponsored by Dr Oade.

Evidence: The following is a summary of timetabled dates where the maternity safety champions meet with the representatives from the Board including the Executive Sponsor - Dr Oade. The Maternity risk report is a standing agenda item and covers the following subjects:

Maternity governance

Quality improvement Initiatives

Perinatal mortality including the quarterly reporting for PMRT and Early Notification Scheme feedback

Investigations

Maternity dashboard


Workforce planning Risk Management Committee (CSU Risk Register Review)

Safety Outcome Subgroup

Quality Management Group

Women’s Governance

7/6/18 - Women’s

9/10/18 18/10/18 2/10/18

6/11/18 - Women’s 17/12/18 15/11/18 6/11/18

6/6/19 - Women’s 27/2/19 20/12/18 4/12/18

9/4/19 21/2/19 8/1/19

20/6/19 21/3/19 5/2/19

18/4/19 2/4/19

7/5/19 5/5/19

13/6/19 4/6/19

In addition to these dates the service is invited to exceptional meetings as required. Papers and minutes from all these meetings can be provided as supplementary evidence if required i.e. ATAIn / PreCept papers June 2019 / QMG agenda item OASI/ Peaches update Dec 2018 The Quality Account has a section maternity with 3rd/ 4th degree tears Maternal & Neonatal Health Safety collaborative Yorkshire & Humber local Learning System :

5/12/18 Attendance sheet identifying LTHT attendance

29/3/19 Learning what we do well presented by Agnes woodhouse for LTHT, QI Midwife

National Learning event for Maternal & Neonatal Safety Collaborative at the Queen Elizabeth Conference Centre, London

25/3/19 - agenda item - ‘Engaging Women and their Families in Improvement


Work’ Sue Gibson and Lucy Potter

10). Have you

reported

100% of

qualifying

Required Standard:

Trust Board sight of Trust legal services and maternity clinical governance records of qualifying Early Notification incidents and numbers reported to NHS Resolution Early Notification team.



2018/ 19

incidents

under NHS

Resolution's

Early

Notification

scheme?

Trust comment:

A Data Base has been developed by the CSU to identify all qualifying incidents:

Term deliveries (> 37+0 completed weeks of gestation), following labour, that resulted in

severe brain injury diagnosed in the first seven days of life. These are babies that fall

into the following categories:

Was diagnosed with grade 3 hypoxic ischaemic encephalopathy (HIE ) or

Was therapeutically cooled (active cooling only) or

Had decreased central tone AND was comatose AND had seizures of any kind

100% of all known qualifying incidents for 2018/19 have been reported to the Trust

under NHS Resolution’s early notification scheme. Maternity services have received

confirmation from the Trust that these received cases have been accepted by the early

resolution team.

Evidence:

NHS Resolution will use data from the National Neonatal Research Database to verify

the Trust’s progress against this action.

The Trust can provide patient identifiers if required to validate this evidence, however

this has not been included in the submission for Information Governance purposes. The

data base is available via the CSU to confirm all identified and notified cases.

Appendix 2 - Copy of Board-declaration-form-and-action-plan-template.

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