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
14 Recommendations
17 Conclusions
1 Report
5 Oral sessions
6 Letters
5 Events
Activity timeline 18 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
2 Feb
2021
Formal meeting (oral evidence session) · Virtual meeting
19 Jan
2021
Oral evidence
19 Jan
2021
Formal meeting (oral evidence session) · Virtual meeting
6 Jan
2021
Correspondence
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 Conclusion
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
24. The Government is considering this recommendation. 25. The inquiry’s report welcomed the recent investment of £95.6m by NHSEI to target the three overarching themes identified in the first Ockenden … Read more
Department of Health and Social Care
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2 Conclusion
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
24. The Government is considering this recommendation. 25. The inquiry’s report welcomed the recent investment of £95.6m by NHSEI to target the three overarching themes identified in the first Ockenden … Read more
Department of Health and Social Care
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3 Recommendation
Fourth Report - The safety of mate…
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
Department of Health and Social Care
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4 Recommendation
Fourth Report - The safety of mate…
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
Department of Health and Social Care
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5 Conclusion
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
36. We accept this recommendation in part. 37. In collaboration with national maternity partner organisations, the MTP has led on the development of a Core Competency Framework to address known … Read more
Department of Health and Social Care
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6 Conclusion
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
36. We accept this recommendation in part. 37. In collaboration with national maternity partner organisations, the MTP has led on the development of a Core Competency Framework to address known … Read more
Department of Health and Social Care
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7 Recommendation
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
Department of Health and Social Care
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8 Conclusion
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
41. We accept this recommendation. 42. In collaboration with national maternity partner organisations including the Royal Colleges, HSIB, NHS Resolution and the CQC, the MTP’s Recommendation’s Group has undertaken a … Read more
Department of Health and Social Care
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9 Recommendation
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
Department of Health and Social Care
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10 Conclusion
Fourth Report - The safety of mate…
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
51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health … Read more
Department of Health and Social Care
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11 Conclusion
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
51. We accept this recommendation in part. 52. HSIB will continue with its existing programme of maternity investigations under the conditions set in the HSIB Maternity Directions 2018. The Health … Read more
Department of Health and Social Care
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12 Conclusion
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
102. We accept this recommendation. 103. NHSEI agrees that all professionals involved in maternity care should be competent and confident in all areas of their work, including when working in … Read more
Department of Health and Social Care
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13 Recommendation
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
Department of Health and Social Care
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14 Recommendation
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
Department of Health and Social Care
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15 Conclusion
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
70. We accept this recommendation in part. 71. We agree that data collection should be streamlined, and that insights collected should be collated in a coordinated way and shared across … Read more
Department of Health and Social Care
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16 Conclusion
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
70. We accept this recommendation in part. 71. We agree that data collection should be streamlined, and that insights collected should be collated in a coordinated way and shared across … Read more
Department of Health and Social Care
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17 Conclusion
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
81. We reject this recommendation. The Government does not intend to put in place a Rapid Redress and Resolution Scheme, as explained in the Department’s evidence to the Committee in … Read more
Department of Health and Social Care
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18 Conclusion
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
85. In order to continue to improve patient safety and address the rising costs of clinical negligence, the Government announced in Spending Review 2020 that it will publish a consultation … Read more
Department of Health and Social Care
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19 Recommendation
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
Department of Health and Social Care
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20 Recommendation
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
Department of Health and Social Care
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21 Recommendation
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
Department of Health and Social Care
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22 Recommendation
Fourth Report - The safety of mate…
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
Department of Health and Social Care
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23 Conclusion
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
106. The Government accepts this recommendation in part. 107. The NHS Mandate7 sets out an aim of year on year reductions in the difference in the stillbirth and neonatal mortality … Read more
Department of Health and Social Care
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24 Conclusion
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
102. We accept this recommendation. 103. NHSEI agrees that all professionals involved in maternity care should be competent and confident in all areas of their work, including when working in … Read more
Department of Health and Social Care
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25 Recommendation
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
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
Department of Health and Social Care
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27 Recommendation
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
Department of Health and Social Care
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28 Conclusion
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
125. We accept this recommendation in part. 126. NHSEI acknowledge concerns about a focus on “normality at any costs”. Our vision is that our staff of all professions and disciplines … Read more
Department of Health and Social Care
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29 Conclusion
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
125. We accept this recommendation in part. 126. NHSEI acknowledge concerns about a focus on “normality at any costs”. Our vision is that our staff of all professions and disciplines … Read more
Department of Health and Social Care
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30 Recommendation
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
Department of Health and Social Care
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31 Recommendation
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
Department of Health and Social Care
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Correspondence 6 letters
7 Jul 2021 Correction to written evidence submitted by NHS Resolution to the Safety of maternity services in England inquiry
Parliament page
6 Jul 2021 Transcript of maternity services roundtable with clinicians on 7 January 2021
Parliament page
15 Jun 2021 To committee Letter from NHS Providers on maternity workforce expansion
Parliament page
25 May 2021 To committee Letter from the Royal College of Midwives on the Committee's inquiry into Safety of maternity services in England
Parliament page
27 Apr 2021 To committee Letter from the Minister of State for Patient Safety, Suicide Prevention and Mental Health on the maternity workforce gap
Parliament page
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
Parliament page