Safety of maternity services in England

Health and Social Care Committee Closed Inquiry
Opened: 24 Jul 2020 Closed: 26 Oct 2021 Parliament page
This inquiry will examine evidence relating to ongoing safety concerns with maternity services. It will build upon investigations that followed incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. We will … Read more
23 Recommendations
8 Conclusions
1 Report
5 Oral sessions
6 Letters
5 Events
Activity timeline 13 events
21 Sep
2021
Report published
7 Jul
2021
Correspondence
6 Jul
2021
Report published
6 Jul
2021
Correspondence
15 Jun
2021
Correspondence
25 May
2021
Correspondence
27 Apr
2021
Correspondence
2 Feb
2021
Oral evidence
19 Jan
2021
Oral evidence
6 Jan
2021
Correspondence
15 Dec
2020
Oral evidence
3 Nov
2020
Oral evidence
Oral evidence sessions 5 sessions
2 Feb 2021
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Dr Matthew Jolly · NHS England Ms Nadine Dorries · Department of Health and Social Care Professor Jacqueline Dunkley-Bent · NHS England and NHS Improvement Sarah-Jane Marsh · NHS England William Vineall · Department of Health and Social Care
19 Jan 2021
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Andrea Sutcliffe · Nursing and Midwifery Council Charlie Massey · General Medical Council Doctor Daghni Rajasingam · The Shelford Group Gill Adgie · Royal College of Midwives Jo Mounfield · Royal College of Obstetricians and Gynaecologists Niamh Maguire · Sussex Local Maternity System Professor James Walker · Healthcare Safety Investigation Branch Sara Ledger · Baby Lifeline
15 Dec 2020
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Clotilde Rebecca Abe · FiveXMore Campaign Donna Ockenden · Independent review into Maternity Services at The Shrewsbury And Telford Hospitals - Maternity Admin Dr Edward Morris · The Royal College of Obstetricians and Gynaecologists (RCOG) Gill Walton · Royal College of Midwives Professor Gordon Smith · University of Cambridge Professor Jenny Kurinczuk · University of Oxford Professor Marian Knight · National Perinatal Epidemiology Unit Tinuke Awe · Five x More
3 Nov 2020
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Darren Smith, bereaved parent Dr Jenny Vaughan · Doctors' Association UK Dr Pelle Gustafson · Swedish Patient Insurer Dr Sonia MacLeod Helen Vernon · NHS Resolution James Titcombe, bereaved parent
29 Sep 2020
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Dr Bill Kirkup · Morecambe Bay maternity investigation and East Kent maternity investigation Dr Matthew Jolly · NHS England Miss Michelle Hemmington · Campaign for Safer Births Professor Jacqueline Dunkley Bent · NHS England and NHS Improvement Professor Ted Baker · Care Quality Commission
Title HC No. Published Items Response
Fourth Report - The safety of maternity services in England HC 19 6 Jul 2021 31 Responded
Recommendations & Conclusions
31 results
1 Recommendation Accepted in Part
Fourth Report - The safety of mate…
The Expert Panel overall rated progress towards safe staffing as ‘Requires Improvement’.
The Expert Panel overall rated progress towards safe staffing as ‘Requires Improvement’. Appropriate staffing levels are a prerequisite for safe care, and a robust and credible tool to establish safe staffing levels for obstetricians is needed. We were pleased that … Read more
Government Response
The government states it is considering the recommendation but confirms its existing commitment to funding the RCOG to develop a workforce planning tool to calculate obstetrician requirements. The response details the tool's purpose but does not explicitly address the recommendation for it to include anaesthetist workforce requirements.
Department of Health and Social Care
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2 Conclusion Deferred
Fourth Report - The safety of mate…
With 8 out of 10 midwives reporting that they did not have enough staff on...
With 8 out of 10 midwives reporting that they did not have enough staff on their shift to provide a safe service, it is clear that urgent action is needed to address staffing shortfalls in maternity services. Evidence submitted to … Read more
Government Response
The government is considering this conclusion, noting recent investment for 1,200 additional midwives and 100 consultant obstetricians and the commissioning of a new workforce planning tool. They will take recommendations on funding for staffing into consideration and assess workforce levels, but do not commit to further funding at this stage.
Department of Health and Social Care
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3 Recommendation Deferred
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We recommend that the budget for maternity services be increased by £200–350m per annum with...
We recommend that the budget for maternity services be increased by £200–350m per annum with immediate effect. This funding increase should be kept under close review as more precise modelling is carried out on the obstetric workforce and as Trusts … Read more
Government Response
The government is considering the recommendation for an immediate budget increase for maternity services, noting recent investment and an ongoing assessment of workforce levels, but does not commit to the specific funding amount or immediate action.
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4 Recommendation Accepted
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We further recommend that the Department work with the Royal College of Obstetricians & Gynaecologists...
We further recommend that the Department work with the Royal College of Obstetricians & Gynaecologists and Health Education England to consider how to deliver an adequate and sustainable level of obstetric training posts to enable trusts to deliver safe obstetric … Read more
Government Response
The government accepts this recommendation, highlighting existing collaboration with HEE and RCOG on workforce planning for obstetrics, gynaecology, and anaesthetics. They note the recent funding for an RCOG tool, to be available next year, which will help NHS Trusts calculate their obstetrician staffing needs.
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5 Recommendation Accepted in Part
Fourth Report - The safety of mate…
The 2016 Maternity Safety Training Fund was widely welcomed by healthcare professionals and it is...
The 2016 Maternity Safety Training Fund was widely welcomed by healthcare professionals and it is clear to us that the Fund delivered positive outcomes. However, for those positive outcomes to endure, more funding is required to embed on-going and sustainable … Read more
Government Response
The government accepts in part, stating that funding was announced in March 2021 for multi-disciplinary team training. NHSEI will undertake further work to align this funding with a Core Competency Framework and monitor its impact on training, also noting existing incentive schemes.
Department of Health and Social Care
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6 Conclusion Accepted in Part
Fourth Report - The safety of mate…
Training is essential for staff to deliver safe care.
Training is essential for staff to deliver safe care. Evidence submitted to our inquiry highlighted that insufficient staffing is not only impacting the number of healthcare professionals available to deliver care for mothers and their babies but also the ability … Read more
Government Response
The government accepts the recommendation in part, citing the development of a Core Competency Framework and allocated funding for multi-disciplinary training and staff backfill. Further work is planned to align this funding with the framework and monitor its impact.
Department of Health and Social Care
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7 Recommendation Accepted in Part
Fourth Report - The safety of mate…
We recommend that a proportion of maternity budgets should be ringfenced for training in every...
We recommend that a proportion of maternity budgets should be ringfenced for training in every maternity unit and that NHS Trusts should report this in public through annual Financial and Quality Accounts. It should be for the Maternity The safety … Read more
Government Response
The government accepts the recommendation in part, confirming funding for maternity training and staff backfill, and the development of a Core Competency Framework. NHSEI will undertake further work to align funding and monitor training, leveraging existing incentive schemes, but does not explicitly commit to ringfencing budgets and public reporting as requested.
Department of Health and Social Care
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8 Conclusion Accepted
Fourth Report - The safety of mate…
While it is encouraging that 93% of trusts are meeting the training objective set out...
While it is encouraging that 93% of trusts are meeting the training objective set out in the Maternity Incentive Scheme, it is disappointing that only 8% of units across the UK are meeting the very highest standards of training, as … Read more
Government Response
The government accepts the recommendation and is developing a Core Competency Framework and a national Registry of Recommendations to address training variations and ensure minimum core requirements for maternity services. They will also work with Royal Colleges and the CQC on standardising fetal monitoring training.
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9 Recommendation Accepted in Part
Fourth Report - The safety of mate…
We recommend that a single set of stretching safety training targets should be established by...
We recommend that a single set of stretching safety training targets should be established by the Maternity Transformation Programme board, working in conjunction with the Royal Colleges and the Care Quality Commission. Those targets should be enforced by NHSE&I’s Maternity … Read more
Government Response
The government accepts the recommendation, describing the development of a Core Competency Framework for essential training targets, with stretch targets to be considered later. While the MTP cannot enforce targets as it is not a regulator, it will collaborate with Royal Colleges and the CQC to share information and support inspection programmes.
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10 Recommendation Accepted in Part
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Involving families in a compassionate manner is a crucial part of the investigation process.
Involving families in a compassionate manner is a crucial part of the investigation process. Too often, maternity investigations have failed to do this in a meaningful way. Families must be confident that their voices are heard and that lessons have … Read more
Government Response
The government accepts the recommendation in part, detailing HSIB's ongoing efforts to improve family engagement and the timeliness of reports through enhanced collaboration, awareness building, and feedback mechanisms. It also notes future provisions in the Health and Care Bill regarding who will carry out maternity investigations.
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11 Recommendation Accepted in Part
Fourth Report - The safety of mate…
We believe that HSIB’s ability to take a broad and independent view of the services...
We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, … Read more
Government Response
The Government accepts the recommendation in part, outlining HSIB's ongoing work to improve the timeliness of investigations, strengthen collaboration with trusts, and enhance engagement with multidisciplinary teams, including through surveys and staff engagement videos.
Department of Health and Social Care
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12 Recommendation Accepted
Fourth Report - The safety of mate…
Clinicians of all disciplines should also receive training before they are qualified in how they...
Clinicians of all disciplines should also receive training before they are qualified in how they should respond to the sorts of error that these investigations may uncover. This would include help for clinicians on accepting a degree of fallibility. Being … Read more
Government Response
The government accepts the recommendation, committing that maternity services will complete a Training Needs Analysis and NHSEI will work with HEE to ensure national training packages support relevant staff, aligning with the Core Competency Framework.
Department of Health and Social Care
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13 Recommendation Accepted in Part
Fourth Report - The safety of mate…
We recommend that HSIB investigations continue, but that HSIB reviews how it engages with trusts...
We recommend that HSIB investigations continue, but that HSIB reviews how it engages with trusts to ensure that the investigation process works in a timely and 54 The safety of maternity services in England collaborative manner which optimally supports local … Read more
Government Response
The Government accepts the recommendation in part, stating HSIB will continue investigations and noting that HSIB has already made changes in the last year to improve timeliness, collaboration, and engagement with trusts and staff, including conducting surveys and creating engagement videos.
Department of Health and Social Care
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14 Recommendation Accepted in Part
Fourth Report - The safety of mate…
In addition, we recommend that HSIB shares the learning from its maternity reports in a...
In addition, we recommend that HSIB shares the learning from its maternity reports in a more systematic and accessible manner. A top level summary of individual cases together with the key learnings derived from them should be shared rapidly across … Read more
Government Response
The Government accepts the recommendation in part, stating HSIB is working with academic partners to develop meaningful data for public sharing, and a new single notification portal (LFPSE) will be commissioned to streamline data collection and sharing across organisations.
Department of Health and Social Care
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15 Conclusion Accepted
Fourth Report - The safety of mate…
We recognise the effort of individual organisations to collect data and insights on maternity care.
We recognise the effort of individual organisations to collect data and insights on maternity care. The potential value of this information to drive improvements in maternity care is clear. However, at present these insights are not being fully utilised. Read more
Government Response
The Government accepts in part, committing to commission a single notification portal (LFPSE) in 2021/22 to streamline data collection and sharing, improve MSDS data, and highlights the existing Maternity Services Dashboard to enhance data utilisation.
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16 Recommendation Accepted in Part
Fourth Report - The safety of mate…
NHSE&I must streamline the data collection process to reduce the burden for trusts.
NHSE&I must streamline the data collection process to reduce the burden for trusts. The Department must ensure that insights collected by all bodies are collated in a coordinated manner and shared across organisations in a timely manner. As part of … Read more
Government Response
The government accepts the recommendation in part, committing to commission a single notification portal in 2021/22 to streamline data collection and enable sharing. It also highlights existing efforts through the CNST MIS and a Maternity Services Dashboard to improve data and identify gaps.
Department of Health and Social Care
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17 Conclusion Rejected
Fourth Report - The safety of mate…
It is clear to us that in its current form the clinical negligence process is...
It is clear to us that in its current form the clinical negligence process is failing to meet its objectives for both families and the healthcare system. Too often families are not provided with the appropriate, timely and compassionate support … Read more
Government Response
The government rejects this conclusion, stating it does not intend to implement a Rapid Redress and Resolution Scheme. This decision was made after a 2017 consultation, as benefits were achieved through other initiatives and the scheme would not address rising clinical negligence costs.
Department of Health and Social Care
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18 Conclusion Deferred
Fourth Report - The safety of mate…
Providing appropriate financial redress to families after an incident is important.
Providing appropriate financial redress to families after an incident is important. However, the rising costs of maternity claims without sufficient learning and outdated mechanisms for calculating compensation is unsustainable. It is particularly unfair that wealthier families receive more compensation for … Read more
Government Response
The government states it will publish a consultation on patient safety and rising clinical negligence costs, with decisions on next steps to be taken after the consultation, thereby deferring action on the issues raised in the committee's conclusion.
Department of Health and Social Care
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19 Recommendation Deferred
Fourth Report - The safety of mate…
While the review of the negligence system is underway, we recommend the Department must implement...
While the review of the negligence system is underway, we recommend the Department must implement the Rapid Redress and Resolution Scheme in full. We also recommend the Department provides the Committee with the scope and timetable for its review of … Read more
Government Response
The government plans to consult on next steps to address clinical negligence costs, stating that decisions will be made following this consultation, rather than committing to implement the Rapid Redress and Resolution Scheme in full or providing a review timetable.
Department of Health and Social Care
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20 Recommendation Deferred
Fourth Report - The safety of mate…
We recommend that following that review, the Department brings forward proposals for litigation reforms that...
We recommend that following that review, the Department brings forward proposals for litigation reforms that award compensation for maternity cases based on whether an incident was avoidable rather than a requirement to prove clinical negligence. That approach would allow families … Read more
Government Response
The government will publish a consultation on litigation reforms to improve patient safety and address rising costs, with decisions on next steps to be taken only after the consultation.
Department of Health and Social Care
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21 Recommendation Deferred
Fourth Report - The safety of mate…
In addition, we recommend that the Department and NHS Resolution remove the need to compensate...
In addition, we recommend that the Department and NHS Resolution remove the need to compensate on the basis of private healthcare provision where appropriate NHS care is available; and that compensation is standardised against the national average wage to prevent … Read more
Government Response
The Government plans to consult on next steps to address the rising costs of clinical negligence, with decisions to be made after the consultation.
Department of Health and Social Care
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22 Recommendation Accepted
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Finally, given their recognition of the role the professional regulators have in ending the blame...
Finally, given their recognition of the role the professional regulators have in ending the blame culture, we recommend that the General Medical Council and the Nursing and Midwifery Council review what changes are required to their remits or working practices … Read more
Government Response
The government welcomes the recommendation, noting that DHSC is working with regulators and highlighting existing work by the GMC and NMC, such as new guidance, outreach sessions, and commissioned research, which are already addressing the blame culture and supporting a just culture within healthcare.
Department of Health and Social Care
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23 Recommendation Accepted in Part
Fourth Report - The safety of mate…
England remains a largely safe place to give birth and efforts to increase the safety...
England remains a largely safe place to give birth and efforts to increase the safety of maternity services have led to further improvements. However, the Expert Panel overall rated the Government’s progress on maternity safety outcomes as ‘Requires Improvement’. The … Read more
Government Response
The government accepts the recommendation in part, noting that health disparities have complex causes beyond the Department's sole remit. It outlines existing initiatives like the NHS Mandate's aim for reduction in disparities, support for PIGF based tests, the Maternity Transformation Programme, and the commitment to Equity Action Plans.
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24 Recommendation Accepted
Fourth Report - The safety of mate…
Having the right skill set, as noted above, is crucial for the successful implementation of...
Having the right skill set, as noted above, is crucial for the successful implementation of continuity of carer. We therefore recommend that those involved in delivering this model have received appropriate training and that all professionals are competent and trained … Read more
Government Response
The government accepts this recommendation, committing to requiring all maternity services to complete a Training Needs Analysis with provided guidance. NHSEI will also work with HEE to ensure national training for 2021/22 supports skill updates for Continuity of Carer teams and care for women from diverse ethnic backgrounds.
Department of Health and Social Care
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25 Recommendation Accepted in Part
Fourth Report - The safety of mate…
Given the underlying causes of these outcomes for women from Black, Asian and minority ethnic...
Given the underlying causes of these outcomes for women from Black, Asian and minority ethnic groups relate to a range of issues beyond the remit of the Department, 56 The safety of maternity services in England we recommend that the … Read more
Government Response
The government accepts this recommendation in part, pointing to the NHS Mandate's aim for year-on-year reductions in health disparities for Black, Asian and Minority Ethnic women. They highlight various ongoing initiatives and Equity Action Plans due by February 2022, but do not commit to a specific target with a clear timeframe to end the disparity as requested.
Department of Health and Social Care
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26 Conclusion
Fourth Report - The safety of mate…
We were pleased to hear that the UK National Screening Committee believed that the current...
We were pleased to hear that the UK National Screening Committee believed that the current evidence for a 3rd trimester breech presentation scan “looks promising” and may be a “suitable candidate for a screening programme once further research had been … Read more
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27 Recommendation Accepted in Part
Fourth Report - The safety of mate…
The central aim of maternity services must be to achieve, in the words of Michelle...
The central aim of maternity services must be to achieve, in the words of Michelle Hemmington, “a safe, healthy, positive experience of birth and to come home with a baby”. And yet, during the course of this inquiry, we heard … Read more
Government Response
The government accepts this recommendation in part, outlining ongoing programmes for personalised and safe care, multi-disciplinary training, and shared decision tools. NHSEI has an improvement oversight group for personalised care and aims for every woman to have a Personalised Care and Support Plan by March 2022. The RCM has also established the Re:Birth Project to develop a consensus on terminology.
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28 Conclusion Accepted in Part
Fourth Report - The safety of mate…
The Expert Panel overall rated the Government’s progress towards providing personalised care as ‘Inadequate’.
The Expert Panel overall rated the Government’s progress towards providing personalised care as ‘Inadequate’. We believe that personalisation must go hand in hand with safety and women must be fully and impartially informed about the safety risks associated with all … Read more
Government Response
The government accepts this conclusion in part, outlining ongoing programmes for personalised and safe care, multi-disciplinary training, and shared decision tools. NHSEI has an improvement oversight group for personalised care and aims for every woman to have a Personalised Care and Support Plan by March 2022, addressing the need for women to be fully informed.
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29 Recommendation Accepted in Part
Fourth Report - The safety of mate…
Timely and appropriate pain relief is also an essential part of safe and personalised care,...
Timely and appropriate pain relief is also an essential part of safe and personalised care, and we believe that every woman giving birth in England should have a right to their choice of pain relief during birth, in line with … Read more
Government Response
The government accepts the recommendation in part, focusing on personalised care, multi-disciplinary training, and shared decision-making tools, with an ambition for every woman to have a Personalised Care and Support Plan by March 2022. It also notes a project to develop consensus on birth terminology.
Department of Health and Social Care
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30 Recommendation Accepted in Part
Fourth Report - The safety of mate…
We recommend that NHS England and Improvement establish a working group comprising of women and...
We recommend that NHS England and Improvement establish a working group comprising of women and their families, organisations providing support for women throughout their pregnancy and clinicians to develop a set of actions for maternity services to consider in order … Read more
Government Response
The government accepts this recommendation in part, stating NHSEI has an improvement oversight group focused on personalised care and support planning, aiming for every woman to have a Personalised Care and Support Plan by March 2022. This addresses the intent for informed choice but does not explicitly commit to establishing the specific working group with the full remit outlined in the recommendation.
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31 Recommendation Accepted
Fourth Report - The safety of mate…
It is deeply concerning that maternity units appear to have been penalised for high Caesarean...
It is deeply concerning that maternity units appear to have been penalised for high Caesarean Section rates. We recommend an immediate end to the use of total Caesarean Section percentages as a metric for maternity services, and that this is … Read more
Government Response
The government accepts this recommendation, agreeing that Caesarean Section rates should not be used for performance management and supports the use of Robson criteria. NHSEI will issue further communication advising against total Caesarean rates and encouraging the intelligent use of Robson group data for quality improvement.
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Government Response AI assessment · 30 of 23 classified
Accepted 7
Accepted in Part 16
Deferred 6
Rejected 1
Total 23 recs + 8 conclusions
Correspondence 6 letters
7 Jul 2021 Correction to written evidence submitted by NHS Resolution to the Safety of maternity services in England inquiry
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6 Jul 2021 Transcript of maternity services roundtable with clinicians on 7 January 2021
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15 Jun 2021 To committee Letter from NHS Providers on maternity workforce expansion
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25 May 2021 To committee Letter from the Royal College of Midwives on the Committee's inquiry into Safety of maternity services in England
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27 Apr 2021 To committee Letter from the Minister of State for Patient Safety, Suicide Prevention and Mental Health on the maternity workforce gap
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6 Jan 2021 To committee Letter from Dr Jenny Vaughan following up from a question asked during the Saftey of maternity services in England session on 3 November
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