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
7 results
Clear
4 Recommendation Accepted
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
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.
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.
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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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.
Department of Health and Social Care
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22 Recommendation Accepted
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
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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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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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.
Department of Health and Social Care
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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
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