3 July 2018

Two reports by the Royal College of Obstetricians and Gynaecologists have been published today which review clinical practice within The Shrewsbury and Telford Hospital NHS Trust’s maternity service.

Since January, when the Trust received the first report, the maternity service has responded to the recommendations and made improvements with pace and focus. This was acknowledged in the Royal College’s follow-up review where it found all recommendations had been addressed and the majority had been achieved.

The review was requested by the Trust following concern over higher than average perinatal mortality rates (still births and deaths within the first seven days of birth).

Sarah Jamieson, the Trust’s Head of Midwifery, said: “We welcome the reports from the Royal College of Obstetricians and Gynaecologists and we are pleased that it has found all its recommendations have now been addressed and the majority achieved.

“We are continuing to focus on the ongoing work to address the outstanding actions which we are on track to deliver. We are committed to continuing our learning and providing the very best care for women and families and this remains our priority.”

There have been a number of improvements made by the service, including:

  • Introducing a number of measures aimed at reducing the number of mums who tragically have stillbirths or experience deaths within the first seven days of their baby’s life. For example:
    • The clinical team meet each week to discuss mums-to-be and babies most at risk to agree how best to monitor, manage risks and care for these women
    • Twice daily multidisciplinary safety huddles to review any emerging issues over the last 12hours
    • Twice weekly CTG (cardiotocography is used during pregnancy to monitor the fetal heart and contractions) meetings where midwives meet with obstetricians to review any learning
    • A smoking cessation midwife is now in post and there has been a reduction in smoking in pregnancy from 21% to 17% in the Telford and Wrekin Clinical Commissioning Group area
    • The Care Group has introduced ‘mama wallets’ for mums-to-be. The wallets contain mums-to-be patient records, and helps women to recognise patterns in fetal movements and raises awareness of what they should do if fetal movements reduce
  • Strengthening the way it manages risk and investigates clinical incidents:
    • There is improved feedback and learning through a weekly newsletter, it’s an agenda item on all serious incident and high-risk cases at ward meetings and there is evidence of learning following the publication of reports such as MBRRACE (Mothers and Babies; Reducing Risk through Audits and Confidential Enquiries report).
    • The Care Group has improved the way it manages risk through for example weekly risk management meetings where all incident reports are reviewed, and weekly executive led rapid review meetings which ensure lessons and necessary improvements are shared and made immediately
    • A risk management midwife is now in post and the planned appointment of a consultant obstetrician with a special interest in risk management will support improvements in the quality of service and governance processes.
    • Following training in October, November and April the Care Group has widened the number of trained investigators that can investigate serious incidents which will improve the quality and timeliness of investigations
    • An external investigator now participates in the investigation of all high-risk incidents (those which are reported externally or require a full investigation)
  • The Care Group’s senior management team have benefited from team work and leadership programmes and this has seen the development of a learning and improving culture among staff as well as improving morale.

A team of seven assessors, which included consultants, midwives and a lay person, visited the Trust from 12 to 14 July 2017. The team undertook site visits, reviewed records of three serious incidents and interviewed staff, service users and their families as well as service user representatives. In addition, a number of documents were also sent to the assessors which included for example policies, audits, surveys and plans. A follow-up review was undertaken in April 2018, where the Trust presented the progress it had made in response to the RCOG recommendations.

You can read the documents here.