Inquiry process 4 panellists and 3 professional advisers Evidence briefing Written submissions from organisations Oral evidence sessions Professional evidence Research with women (Picker Institute) Visits

Key findings and recommendations Patient safety and the maternity services Maternity services in context Safe maternity teams Staffing for safety Training for safety Guidance on safe practice Information for safety The role of trust boards National structures for safety

Patient safety and the maternity services ‘the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of health care’ (Vincent 2007) Safety is achieved partly through the dedication and vigilance of individual clinicians, mothers and families, and partly by robust processes and systems of care.

Patient safety and the maternity services

2. Maternity services and their context RECENT PRESSURES  Rising birth rates  Older motherhood  Problems caused by fertility treatment  Increased obesity  Survival of critical illness in childhood  More surgical intervention  Challenges presented by some forms of social & cultural diversity ACHIEVEMENT The fact that reductions in maternal and perinatal mortality have been achieved in spite of these pressures should be recognised as a major achievement. 8 Safe Births

3. Safe maternity teams PROBLEMS  Interprofessional relationships  Difficulties with leadership and management  Difficulties with communication SOLUTIONS Clarity about team objectives and roles Effective leadership Clear and agreed procedures for communication 9 Safe Births

4. Staffing for safety PROBLEMS  Shortage of midwives  Inadequate consultant cover  Inexperience  Administrative overload  Inappropriate deployment of clinical skills SOLUTIONS The right staff in the right place at the right time Review demand and capacity regularly National bodies to provide simple and effective tools to help managers 10 Safe Births

5. Training for safety PROBLEMS  Poor uptake of training  Lack of specific safety training SOLUTIONS Teams that work together should also train together Simulation-based training Safety awareness training 12 Safe Births

6. Guidance on safe practice PROBLEMS  Guidelines not available  Guidelines not useful SOLUTIONS Single set of evidence-based guidelines Short summaries and one-page protocols All staff trained to use protocols 13 Safe Births

7. Information for safety PROBLEMS  Information not useful  Time-wasting systems SOLUTIONS Manageable amount of information on own and national performance A small set of reliable information measures Simple systems for capturing information on safety 14 Safe Births

8. The role of trust boards PROBLEMS  Low priority for maternity  Poor focus on safety SOLUTIONS Prioritise safety Educate board members Governance structures Improve understanding of local safety issues Regard safety as a business imperative 15 Safe Births

9. National structures for safety PROBLEMS  Administrative overload  Poor co-ordination  Low priority for maternity safety  CNST standards  Poor impact of recent NHS reforms  Poor regional planning & support SOLUTIONS Standards set and monitored by one body Distil existing standards Offer special support to trusts undergoing reconfiguration Financial incentives aligned to promote the safest care 16 Safe Births

Royal College of Obstetricians and Gynaecologists  Setting standards to improve women’s health  Risk Management and Medico-Legal Issues In Women’s Health  Joint RCOG/ENTER Meeting  Please turn off all mobile phones and pagers