RISK MANAGEMENT POLICY FOR MATERNITY. Documentation Control

RISK MANAGEMENT POLICY FOR MATERNITY Documentation Control Reference GG/CM/016 Approving Body Trust Board Date Approved Implementation Date Supersedes NUH Risk Management Strategy for Maternity and Gynaecology Version 2 (October 2008) Consultation Consultant Obstetricians and Gynaecologists Corporate Risk Leads Senior Midwives Clinical Risk Committee Directors Group Date of Completion of 19 February 2010 Equality Impact Assessment Target Audience All Maternity Unit Clinical areas Senior Midwifery, Obstetric & Gynaecology staff Summary to all Obstetric & Gynaecology staff via intranet Supporting Documents and NUH Risk Management Policy, March 2010 References Review Date Anually Lead Executive Medical Director Author/Lead Manager Head of Midwifery, Maternity Risk Coordinators Further Maternity Governance Lead Guidance/Information Maternity Risk Co-ordinators Linkages with Trust Risk Management Policy March 2010 Nottingham Primary Care Risk Management Strategy

CONTENTS PAGE 1. Introduction Page 3 2. Statement of Philosophy Page 3 3. Policy Statement Page 4 4. Key Measurable Objectives Page 5 5. Leadership Page 6 6. Roles and Responsibilities Page 7 7. Systems and Processes for Managing Risk Page 11 8. Complaints Page 14 9. Claims Page 14 10. Responsibilities of Speciality Groups Page 14 11. Review of the Strategy Page 17 12. References Page 17 13. Equality and Diversity Statement Page 18 14. Equality Impact Statement Page 18 Appendix 1 Reporting Structure Page 20 Appendix 2 Process for Monitoring the Key Measurable Objectives Page 21 Appendix 3 Maternity (Obstetrics & Gynaecology) Dataset Page 24 Appendix 4 Equality Impact Assessment Page 26 Appendix 5 Employee Record Of having Read The Policy Page 31 2

Nottingham University Hospitals NHS Trust Maternity Risk Management Strategy 1. Introduction 1.1 The Nottingham University Hospitals NHS Trust is committed to providing an environment which minimises risk and promotes the health, safety and well-being of all those who enter or use its premises whether as staff, patients, visitors or contractors, and this is clearly set out in the Trust Risk Management Policy (2010). 1.2 The Maternity Risk Management Policy reflects the principles contained in the Trust Risk Management Policy (2010), thus facilitating a consistent approach to managing risk and patient safety. There are a number of key roles and responsibilities outlined in section five of the Trust Risk Management Policy (2010) which support the implementation of the Maternity Risk Management Policy. The Maternity Risk Management Policy should therefore be read in conjunction with the Trust Risk Management Policy (2010). 1.3 The Maternity Risk Management Policy describes how risk is managed within the Maternity Services provided by the Nottingham University Hospitals NHS Trust on the City Hospital Campus and the Queens Medical Centre Campus. It is applicable to all staff who work within the specialty. This includes staff whose primary base is not maternity services (e.g. anaesthetists, theatre staff, professionals allied to medicine etc). 1.4 The implementation of the Maternity Risk Management Policy is underpinned by the Trust Incident Reporting and Management Policy (2009), the Trust Claims Handling Policy and Procedure (2008), and the Trust Serious Untoward Incident Policy and Procedures (2009). 2. Statement of Philosophy 2.1 The Maternity Service is committed to the provision of high quality care tailored to meet the needs of the woman and her family. 3

2.2 The Maternity Service is committed to achieving an integrated system of governance focussing on continuous improvements in quality and in the control and reduction of risk. 2.3 The Maternity Service supports an open, honest and participative culture where clinical incidents are reported, lessons are learned, and where appropriate systems of care are improved as a result. 3. Policy Statement 3.1 The Trust accepts that the provision of maternity care is, by its nature, a high-risk activity. Proactive risk management is therefore integral to the reduction of risk and the promotion of quality. 3.2 The maternity service adopts an integrated approach to managing risk, which aims to either eliminate or control identified risks. These may be clinical, organisational, health and safety or financial; and may involve current services, or be identified through the annual planning process. 3.3 The maternity service recognises that ongoing risks which cannot be addressed within the Directorate will be accepted or, in the case of significant risks, shared with the Trust Board, commissioners of services, members of the healthcare community and other stakeholders. 3.4 There is an organisational reporting structure which supports the implementation of the Maternity Risk Management Policy (Appendix 1). 3.5 The staff working in the maternity service are central to the implementation of the Maternity Risk Management Policy; therefore all staff have a responsibility to; Be aware of the principles of risk management; Adopt appropriate practices to reduce risk; Comply with Trust and Speciality policies, procedures and guidelines; To identify and report potential or actual risks; Follow the Trust Incident Reporting and Management Policy (2009); Produce accurate and legible documentation of care; 4

Attend appropriate mandatory training; Engage with service users to enhance quality; 4. Key Measurable Objectives 4.1 The Family Health Directorate is committed to reducing healthcare risks and to implementing risk management at all levels throughout the maternity service. Our key measurable objectives to achieve this are to: Provide staff training to enhance safe practice appropriate to individual roles and responsibility, as set out in the Multidisciplinary Training Needs Analysis (2010). Provide cohesive risk management training, support and assistance to all staff delivering maternity services. Proactively assess risk and address issues identified to minimise future risks to patients, staff, visitors, contractors and/or the Trust, and ensure they are added to the Directorate Risk Register in accordance with the Trust Risk Management Policy (2010) and supporting the Hazard Identification, Risk Assessment And Management Procedure (2010). Ensure that all clinical guidelines are reviewed at least every three years, and are evidence based, referenced and reflect best practice principles. Identify opportunities to improve patient care, and make changes to clinical practice/policy formation through systematic review and analysis of all formal risk assessments, incidents, near misses, complaints (patient experience) and clinical claims. Ensure the timely dissemination of learning outcomes to all appropriate staff and departments. Ensure the delivery and review of action plans and risk assessements. Achieve NHSLA Maternity Clinical Risk Management Standards. 5

Report incidents where appropriate to other agencies e.g. NPSA, PCT, HSE, CMACE, LSA Regional Midwifery Officer, the Director of Public Health, NHS Litigation Authority. Consider lessons learned from external agencies and organisations. Consider the recommendations published in related national maternity reports, e.g. CMACE, NICE, NSF, HCC, CQC. 4.2 Process for Monitoring the Objectives The Specialty Clinical Governance Meeting has overall responsibility for monitoring the objectives set out within the Maternity Risk Management Policy. The process for monitoring the objectives is set out in Appendix 2. 5. Leadership 5.1 The Trust believes that effective risk management is an integral function of all operational activity, and has implemented internal structures to develop and maintain an environment where risks are minimised and managed. 5.2 The Chief Executive (CEO) has overall accountability for ensuring that there are suitable and robust risk management systems in place to safely deliver all of the Trust s services. The CEO ensures that the Trust operates its activities in compliance with all relevant statutory requirements and Department of Health guidance. The CEO is supported at Trust Board level by all the Board Directors as outlined in the Trust Risk Management Policy (2010). 5.3 The named lead executive at Trust Board Level with responsibility for maternity services is the Medical Director. The Medical Director is a member of the Trust Directors Group and the Trust Quality, Safety And Risk Committee and has delegated responsibility for the strategic development, implementation and monitoring of: Trust Integrated Governance Trust Risk Management 6

Trust Clinical Quality and Clinical Effectiveness Effective liaison with the maternity service; including the escalation of risk issues and serious untoward events. 5.4 The Family Health Clinical Director is a member of the Trust Quality, Safety And Risk Committee. 5.5 The Head Of Midwifery is a member of the Trust Clinical Risk Committee. 5.6 The Family Health General Manager is a member of the Trust Organisational Risk Committee. 5.7 A nominated consultant is a member of the Trust Clinical Effectiveness Committee. 6. Roles and Responsibilities 6.1 The Clinical Director for Family Health and the Head of Midwifery are operationally responsible for the implementation of risk management. 6.2 The Clinical Director is responsible for: The implementation of the Maternity Risk Management Policy within the service. Appointing a Medical Consultant Clinical Lead for Risk Management. Appointing a Medical Consultant Clinical Lead for Governance. Ensuring that an effective local Directorate Governance Forum is in place. Ensuring that relevant aspects of healthcare standards are managed within the service. Ensuring that risks are reported to the Trust in accordance with the Trust s Risk Management Policy (2010). Reporting significant risks to the Trust Quality, Safety And Risk Committee and, where appropriate, ensuring escalation to the Board. 6.3 The Head of Midwifery is responsible for: The implementation of the Maternity Risk Management Policy within the Department. 7

Appointing the Maternity Risk Coordinators. Appointing the Maternity Governance Lead. Ensuring that risks are appropriately investigated and managed; and where necessary escalated. Ensuring that reports are provided in a timely fashion to the Trust Clinical Risk Committee. Ensuring effective two-way communication between the Specialty and the Trust Clinical Risk Committee. Providing a bi-annual incident trending report to the Trust Clinical Risk Committee and the Trust Board. Ensuring that SUI action plans are submitted and reviewed at Trust Clinical Risk Committee and the Directorate Clinical Governance Meetings and Clinical Governance Forum. 6.4 It is the joint responsibility of the Maternity Governance Lead and the Medical Consultant Clinical Lead for Governance to: Improve quality and safeguard standards of care. Receive the minutes and reports of the two campus based Maternity Risk Management Meetings and Labour Ward Forums and ensure appropriate action is taken based on feedback. Provide guidance, advice and support for staff in achieving the CNST standards and other relevant Healthcare Standards. Review Confidential Enquiries and other national reports and take action where necessary. Contribute to the development and implementation of local policies, guidelines and procedures. Ensure that specialist advisors are consulted as appropriate and their recommendations followed. Ensure that any governance issues, including risks that cannot or should not be managed at Speciality level are incorporated into a Directorate Governance Action Plan and escalated to the Trust Quality, Safety And Risk Committee. 6.5 It is the joint responsibility of the Maternity Risk Co-ordinators and the Medical Consultant Clinical Leads for Risk Management to: Implement the Maternity Risk Management Policy and associated policies and procedures. Raise the profile of Maternity Risk Management in the Speciality. Ensure that all staff are aware of the existence of the Maternity Risk Management Policy. 8

Implement the local and Trust policy and procedures on incident reporting. Report risk issues to the Directorate in line with the Trust process. Liaise closely with the Maternity Governance Lead. Chair the monthly Specialty Risk Management meeting. Reporting monthly to the Specialty Clinical Governance Meeting. Assist with root cause analyse investigations and/or ensure that root cause analyses are carried out where appropriate. Ensure appropriate cases are discussed at the speciality risk management meetings and action plans put in place, where appropriate, to address issues arising from cases and ensure actions are followed up. Review action plans from SUI reports and monitor their implementation. 6.6 It is the responsibility of the Clinical Director to appoint a Lead Consultant Obstetrician for each Labour Ward. 6.7 It is the responsibility of the Labour Ward Lead Consultant Obstetrician to: Work with the Labour Ward Midwifery Managers to contribute to the development of relevant policies, guidelines and procedures and to ensure that they are implemented. Participating in the multidisciplinary Labour Ward Groups and cross city Labour Ward Forum. Contribute to the mandatory obstetric emergency skills drills training. Actively participate in incident reporting and risk investigations. Attend the Specialty Risk Management Meetings. Liaise with the Maternity Governance Team regarding clinical incidents involving Labour Ward. 6.8 It is the responsibility of the Head of Midwifery to appoint Labour Ward Midwifery Managers for each Labour Ward. 6.9 It is the responsibility of the Labour Ward Midwifery Managers to: Work with the Labour Ward Lead Consultant Obstetrician to contribute to the development of relevant policies, guidelines and procedures and to ensure that they are implemented. 9

Participate in the multidisciplinary Labour Ward groups and cross city Labour Ward Forum. Contribute to the mandatory obstetric emergency skills drills training. Actively participate in incident reporting and risk investigations, including pro-active identification of clinical and non-clinical risks and their management. Attend the Specialty Risk Management Meetings. Liaise with the Maternity Governance Team regarding clinical incidents involving Labour Ward. 6.10 It is the responsibility of the Anaesthetic Clinical Director to appoint for each Labour Ward a Lead Obstetric Anaesthetist. 6.11 It is the responsibility of the Lead Obstetric Anaesthetist to: Take responsibility for the anaesthetic services within the maternity unit, ensuring its effective functioning is supported by policies, procedures and guidelines. Oversee the relevant and requisite obstetric anaesthetic audits. Actively participate in incident reporting and risk investigation. Participate in the multidisciplinary Labour Ward Groups. Participate in the Labour Ward Forum. Report to the Anaesthetic Directorate about the relevant Labour Ward issues. Contribute to the mandatory obstetric emergency skills drills training. 6.12 The Matron, Departmental and Ward Managers are responsible for ensuring that appropriate standards of quality and safety are maintained in the areas under their managerial control. 6.13 The Supervisors of Midwives support the risk management process by safeguarding the quality of maternity care. Specific risk management duties of the Supervisors of Midwives include:- The promotion of evidence based practice; including participation in the development of policies, guidelines and procedures. 10

Annual supervisory reviews to ensure midwives are fit to practice, and to identify training or personal developmental needs. Representation at the Specialty risk management meetings, labour ward meetings and clinical governance group. Assistance in the internal and external investigation of incidents and SUI s, and any subsequent recommendations. The provision of professional advice on a 24 hour on call basis. To advise the Head of Midwifery of any risk management issues. To participate in the Local Supervising Authority (LSA) supervisory investigation process at the request of the LSA Midwifery Officer. 6.14 All staff are accountable for their own working practice and behaviour this is implicit in contracts of employment, reflected in individual job plans / descriptions, and described in the Trust Risk Management Policy (2010). 7. Systems and Processes for Managing Risk Incident and Near Miss Reporting Process 7.1 The routine reporting of patient safety incidents, accidents and near misses is an essential component of the Maternity Risk Management Policy. 7.2 There is local guidance for staff on what should be reported. The Obstetric and Gynaecology Dataset is found in Appendix 3. 7.3 Incidents are reported by staff and can be documented on either a NUH Patient Safety Incident Report Form, or a NUH Non-patient Safety Incident Report Form 7.4 NUH Incident Report Forms are located in the blue Incident Reporting Policy And Procedures Manual (2009) which are located in all the clinical areas. 7.5 The incident form is triaged by the Maternity Risk Coordinators who decide who will investigate the incident. Incidents involving predominantly medical practice will be given to a Consultant to investigate. Health and safety incidents will be investigated by 11

Health and Safety links. Commonly occurring incidents involving predominantly midwifery practice will be investigated by Supervisors of Midwives/Senior Midwives. More complex midwifery/management incidents will be investigated by the Ward Manager with reference to the Maternity Governance Lead or Maternity Risk Co-ordinators as appropriate. Community related incidents which arise are referred to the appropriate Risk Manager in the geographical area. 7.6 The completed incident and investigation forms are sent to the Maternity Risk Co-ordinators who photocopy the forms, file locally and complete the local database. 7.7 The original forms are forwarded to the NUH Integrated Governance Team for entry onto the Datix system. 7.8 Actions arising out of incidents and investigations are minuted in the Specialty Risk Management Group Meetings, which includes a responsible lead for each action. All identified governance issues are reported to the Specialty Clinical Governance Meeting. 7.9 Lessons learned are dealt with on an individual basis with the staff involved and all staff are made aware through a variety of media, for example: guideline change, staff bulletin Practice, Risk Audit In Maternity (PRAM), mandatory training, management and ward meetings, and Midwifery Supervision. 7.10 The Specialty Risk Management Groups and the Specialty Clinical Governance Group receive from the Maternity Risk Co-ordinators both a monthly and a quarterly report with recommendations. Management of a Serious Incident 7.11 When a serious incident has taken place the Trust Serious Untoward Incident Policy and Procedures (2009) must be initiated immediately by the most senior manager on duty. 7.12 Staff must take all immediate, appropriate action to ensure the safety and wellbeing of the patient, staff or visitor affected by the incident. 7.13 All high level / potential Serious Untoward Incidents (SUI s) are immediately escalated to Directorate and Trust level. During office hours this communication will take place through the Trust Risk 12

Manager. Out of hours initial communication will take place through the Director on call for the Trust. The Maternity Risk Co-ordinator will initiate preliminary measures, for example photocopying of medical records, requesting statements, undertaking case review for discussion at specialty risk management meetings. The Trust Medical Director will review the case and, if necessary, an investigation panel will be appointed, to include unbiased external input. 7.14 An action plan will be generated following the investigation and submitted to the Trust Clinical Risk Committee. The Specialty Clinical Governance Meeting will monitor the progress of the actions and provide regular reports to the Trust Clinical Risk Committee until the actions are complete. 7.15 Support for staff may be provided by their line manager, educational supervisor, supervisor of midwives or the occupational health services, dependant upon individual circumstances. 7.16 If the Local Supervising Authority Midwifery Officer recommends an investigation of midwifery practice this will be conducted by a Supervisor of Midwives. The conclusions and recommendations of the supervisory investigation are forwarded to the Head of Midwifery. Risk Assessments and the Risk Register (This should be read in conjunction with section 6 of the Trust Risk Management Policy, 2010) 7.17 Risks may be identified through a variety of routes eg. incidents, complaint, or claims; a review of a process or activity or the delivery of a service. 7.18 Risks should be rated using the Trust likelihood/consequence matrix as described in the agreed Trust Hazard Identification Risk Assessment And Management Procedure (2010). 7.19 Completed risk assessments are then discussed and agreed at the Specialty Clinical Governance Meeting and are entered onto the Directorate Risk Register. The Risk Register is monitored on a monthly basis by the Specialty Clinical Governance Meeting and the Directorate Governance Forum. 7.20 Risks scoring >15 or above must be communicated to the Clinical Director and the Head of Midwifery who will ensure they are 13

8. Complaints escalated in accordance with the Trust Risk Management Policy (2010) statement on levels of risk, reporting and accountability. 8.1 Complaints are managed by the Speciality Matron in line with The Trusts Management of Complaints, Concerns, Comments and Compliments Policy (2010) and the support of the Patient Experience Team. 8.2 Complaints are reviewed and monitored at the Specialty Clinical Governance Meeting and the Directorate Governance Forum. The Matron has responsibility for ensuring that any action plans are implemented and reviewed. Individual feedback is given to staff members as appropriate and lessons learnt are disseminated through the Practice, Risk Audit In Maternity (PRAM) newsletter. Targeted feedback is also given at doctors and midwives induction sessions which are facilitated by the Matron. 9. Claims 9.1 Claims are presented at the Specialty Clinical Governance Meeting by the Trust Claims Manager on a quarterly basis. Individual feedback is given as appropriate and lesson learnt are disseminated through PRAM newsletter. Targeted feedback is also provided at doctors and midwives induction sessions facilitated by the Maternity Governance Lead. 10. Responsibilities of specialty groups 10.1 Directorate Governance Forum To receive and monitor updates from the Directorate subgroups in all aspects of clinical governance and risk. To ensure that the Directorate reviews all national recommendations. To ensure that all services provided by the Directorate meet best practice recommendations. To promote patient safety through incident reporting and maintenance of the Directorate Risk Register. 14

To manage risks and action plans as required. 10.2 Specialty Clinical Governance Meeting To promote the quality agenda within the maternity service. To receive the minutes and reports of the two Risk Management committees and labour ward and ensure appropriate action is taken based on feedback. To identify significant risks which need adding to the Directorate Risk Register, and review risk scores ongoingly. To provide guidance, advice and support for staff in achieving the NHSLA maternity standards. To review and take action on (where necessary) Confidential Enquiries and other national reports (e.g. NICE guidance, NSF). Oversee implementation of actions following Serious Untoward Incidents and implement action plans following root cause analyses. To provide assurance on safeguarding. To monitor the educational strategy. To manage risks and action plans as required. 10.3 Risk Management Groups To oversee the risk management process within the specialty. To raise the profile of risk management within the specialty. To report risk issues to the Directorate in line with the Trust process. To achieve an objective multidisciplinary review of cases and a consensus view. To oversee the implementation of actions and recommendations arising from investigations into clinical incidents / near misses. To manage risks and action plans as required. To review trends and recommend actions as required. To receive feedback on all current and potential claims against the Trust. 15

10.4 Labour Ward Groups / Quarterly Joint Forum To review all aspects of labour ward activity and to look at professional (clinical) issues, organisational issues and decision making. To review intrapartum policies, procedures and guidelines. To monitor staff training and educations. To consider organisational issues eg security, visiting etc To discuss feedback and trends from incident reporting. To contribute to the implementation of the NHSLA maternity standards. To manage risks and action plans as required. 10.5 Guideline group To oversee the production of evidence-based, multidisciplinary guidelines for the care of women during pregnancy and childbirth by: Identifying key individuals with responsibility for writing guidelines. Circulating guidelines in draft format to relevant members of the multidisciplinary team and inviting comment. Receiving comment from the team and amending guidelines appropriately. Checking that the guideline is in line with national guidelines and recommendations from NICE. To review guidelines from other sources and adopt for optimum local use. To act as the forum whereby amended guidelines are ratified prior to distribution across the Trust. Ratification should take place within 2 months of approving final draft of guideline. To register evidence based guidelines that have been developed by an appropriate group of individual and that have been peer-reviewed, including guidelines developed by this group. To maintain a register of guidelines that identifies which guidelines are due for review and maintain a work plan to ensure that guidelines are regularly reviewed. To ensure that guidelines are disseminated, following ratification, to all members of the multidisciplinary team and put into the Trust electronic library. 16

10.6 Supervisors of Midwives The group supports Midwifery Supervisors in the execution of their role. The group monitors statutory supervisory activity. This group provides the interface between the supervisors at the Trust and the Regional LSA Midwifery Officer. 10.7 Joint Senior Midwives To share and discuss specialty information with relevant senior midwives. To ensure the smooth operational functioning of the department and make changes in response to service demand. To oversee the implementation of quality assurance measures eg. Infection control principles, educational strategy etc 10.8 CNST Action Group To receive reports and action plans from each of the five CNST Standard Leads. To monitor compliance against action plans for achievement of CNST accreditation at Level 3. To support CNST Standard Leads in delivering action plans. To provide bi-monthly assurance reports to Directorate Clinical Governance Forum against progress towards achievement of CNST Level 3. To monitor the completion of Evidence Template for CNST Level 3. 11. Review of the Strategy The Maternity Risk Management Strategy will be reviewed annually and ratified at the Specialty Clinical Governance Meeting, and at Trust Board. 12. References NUH Trust Risk Management Policy (2010) Corporate Governance Framework Manual, December 2009 NHSLA Maternity Risk Management Standards 2010/2011 17

NUH Hazard Identification, Risk Assessment And management Procedure (2010) NUH Claims handling and policy procedure (2008) NUH Management of Complaints, Concerns, Comments and Compliments Policy (2010) NUH Serious Untoward Incident Policy And Procedure (2009) NUH Incident And Reporting Policy (2009) Development, Approval, Implementation and Review Policy, 2010 13. Equality and Diversity Statement 13.1 All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment. 13.2 All Trust Polices and Trust wide Procedures must comply with the relevant legislation (non exhaustive list) where applicable: Equal Pay Act (1970 and amended 1983) Sex Discrimination Act (1975 amended 1986) Race Relations (Amendment) Act 2000 Disability Discrimination Act (1995) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act 1999 Code of Practice on Age Diversity in Employment (1999) Part Time Workers - Prevention of Less Favourable Treatment Regulations (2000) Civil Partnership Act 2004 Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001) Employment Equality (Sexual Orientation) Regulations 2003 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Age) Regulations 2006 Equality Act (Sexual Orientation) Regulations 2007 18

14. Equality Impact Assessment Statement 14.1 NUH is committed to ensuring that none of its policies, procedures, services, projects or functions discriminate unlawfully. In order to ensure this commitment all policies, procedures, services, projects or functions will undergo an Equality Impact Assessment. 14.2 Reviews of Equality Impact Assessments will be conducted in line with the review of the policy, procedure, service, project or function. (Appendix 4). 19

ORGANISATIONAL REPORTING STRUCTURE APPENDIX 1 Trust Board Directors Group NUH Quality, Safety And Management Committee Organisational Risk & Patient Partnership Committee Trust Clinical Risk Committee Clinical Effectiveness Committee Directorate Governance Forum Specialty Clinical Governance Meeting CNST Action Group Specialty Risk Management Meetings Labour Ward Groups/Forum 20

Process for monitoring key objectives APPENDIX 2 Objective Clinical Lead Operational Monitoring Group 1 Provide staff training as set Practice Specialty Clinical out in the Maternity Services Development Governance Meeting Multidisciplinary Training Matron Schedule. 2 Provide cohesive risk management support and assistance. Specialty Risk Co-ordinators 3 Proactively assess risk. Specialty Risk Co-ordinators / Ward Managers / Matrons 4 Production of evidence based guidelines Chair of Guidelines Group Specialty Risk Management Groups Specialty Clinical Governance Meeting/ Specialty Risk Management Groups Labour Suite Groups / Forum Evidence Source Training needs analysis report Lesson plans /Attendance Lists Risk Management Meetings Reporting process Recent assessments Specialty intranet site. Minutes of meetings. 5 Analysis of incidents. Specialty Risk Co-ordinators / Matrons / Governance Leads Directorate Governance Forum / Specialty Clinical Governance Meeting/ Specialty Risk Minutes of meetings Trends analysis Risk Register Maternity Dashboard

Management Groups 6 Dissemination of learning outcomes. 7 Implementation and review of action plans. 8 Achieve NHSLA Maternity Standards. 9 Report incidents to other agencies. 10 Consider lessons learned from external sources. Specialty Risk Co-ordinators / Matrons/ Governance Leads Specialty Risk Co-ordinator / Matrons/ Governance Leads CNST Action Group / Standard leads Head of Midwifery / Specialty Risk Co-ordinators Head of Midwifery / Directorate Risk Coordinators / Governance Directorate Governance Forum / Specialty Clinical Governance Meeting /Specialty Risk Management Groups Directorate Governance Forum / Specialty Clinical Governance Meeting / Specialty Risk Management Groups Directorate Governance Forum / Specialty Clinical Governance Meeting Directorate Governance Forum / Specialty Clinical Governance Meeting Directorate Governance Forum/ Labour Ward Forum/ Specialty Clinical Governance Meeting Minutes of meetings Policy changes Staff bulletin (PRAM) Minutes of meetings Minutes of meetings Electronic evidence template Agency specific documentation Letters / e-mails Minutes of meetings Gap analysis evidence 22

11 Consider the recommendations from national reports. leads Head of Midwifery / Directorate Risk Coordinators / Governance Leads Directorate Governance Forum/ Specialty Clinical Governance Meeting/ Specialty Risk Management Groups Minutes of meetings Gap analysis evidence 23

Maternity (obstetrics & gynaecology) dataset APPENDIX 3 Caesarean - hysterectomy / laparotomy performed during CS Eclamptic fit / eclampsia Third / fourth degree tears / extensive genital trauma Major hemorrhage =>1000ml or hypovolaemic shock Postnatal Hb <8g/mmol Maternal collapse requiring resuscitation Maternal death Ruptured uterus Undiagnosed breech Shoulder dystocia Intermittent self catheterization related to bladder over distension Unsuccessful forceps / ventouse performed in the labour room Postnatal readmission of mother GBS +ve woman not managed according to guideline Resuturing of perineum Delay of >30 minutes for Category 1 CS Incorrect disposal of products of conception Maternity Unit closed to admissions Ruptured ectopic pregnancy Failed sterilization Failed termination Fistula following surgery Ovarian hyperstimulation Unexpected return to theatre Failure to perform treatment / procedure Retained swab / instrument - Use codes in Treatment & Procedure section Damage to organs / structures at operation - Use code in Treatment & Procedure section Pulmonary embolus / deep vein thrombosis - Use code in Patient Care section Anaesthetic complications - Use codes in Patient Care and Treatment & Procedure sections O&G - Unexpected admission to Critical care - Use code in Access, Admission, Transfer & Discharge section Undiagnosed fetal abnormality Intrauterine fetal death / still birth neonatal Death Unexpected admission to neonatal unit Cord PH < 7.05 arterial, < 7.1 venous Apgar < 7 at 5 minutes

Neonatal injury at birth [e.g. fracture, cuts, laceration at CS or neurological injury] Advanced neonatal resuscitation Blood loss in neonate Unplanned delivery at home or in transit to Maternity Unit Both identity labels missing 25

APPENDIX 4 1. Name of Policy or Service EQUALITY IMPACT ASSESSMENT Maternity Risk Management Strategy 2. Responsible Manager Paula Schofield, Maternity Governance Lead 3. Name of Person Completing Assessment Gill Perkins 4. Date EIA Completed 13 5. Description and Aims of Policy/Service (including relevance to equalities) This Policy sets out the aims of the maternity services at Nottingham University Hospitals NHS Trust (NUH) in managing risks to patients, staff, visitors and contractors, and to service quality, and describes a framework for the integration and development of the maternity specialty risk management process. The maternity risk management strategy reflects the principles of the Trust Risk Management policy, which encompasses all aspects of risk management. 6. Brief Summary of Research and Relevant Data DATIX Risk Registers 7. Methods and Outcome of Consultation Trust Board Directors Group Chairs CRC Chairs CEC ORPPC 26

THSC Obstetric & Gynaecology Risk Management groups Specialty Clinical Governance Group 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Assessment of Impact Age Low + Gender Low+ Race Low+ Sexual Orientation Low+ Religion or belief Low+ Disability Low+ Dignity and Human Rights N/A Working Patterns Low+ Social Deprivation N/A 9. Decisions and/or Recommendations (including supporting rationale) A full impact assessment is not required as it is not thought to have a negative impact on the diverse groups. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements (including date of next full review) Monitoring of Risk Registers by ORPPC Incidents reported on DATIX Incidents reported to THSC Next Full Review: December April 2011 *The sections in bold must be included within every EIA Report; a full impact assessment will also contain the remaining section 27

Screening Grid Age Equality Area Key Equalities Legislation / Policy (See summary sheet) Age Regulations 2006 Is this policy or service RELEVANT to this equality area? YES / NO Yes Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive (+) negative (-) Low Reasons for Assessment There is no differential impact for employees in relation to their age Gender Race Sex Discrimination Act 1975 Equal Pay Act 1970 Equalities Act 2006 Gender Recognition Act 2004 Race Relations Act 1976 Race Relations (Amendment) Act 2000 Yes Yes Low Low This policy has been written to ensure that all staff are provided with a clear understanding of the specialty s requirements in the management of risks irrespective of gender. This policy has been written to ensure that all staff are provided with a clear understanding of the specialty s requirements in the management of risks irrespective of race. This policy can be produced in alternative languages of required. 28

Sexual orientation Religion and beliefs Disability Equalities Act 2006 Relevant employment legislation Equalities Act 2006 Relevant employment legislation Disability Discrimination Act 1995 and 2005 Yes Yes Yes Low Low Low This policy has been written to ensure that all staff are provided with a clear understanding of the specialty s requirements in the management of risks irrespective of sexual orientation. There is no differential impact for the target audience in relation to their religion or beliefs, therefore it is believed to have a positive impact. This policy has been written to ensure that all staff are provided with a clear understanding of the specialty s requirements in the management of risks irrespective of disability. This policy can be produced in alternative formats if required. Dignity and Human Rights Human Rights Act 1998 (relevant articles) No 29

Working Patterns The Part-time Workers (Prevention of Less Favourable Treatment) Regulations 2000 Yes Low This policy has been written to ensure that all staff are provided with a clear understanding of the specialty s requirements in the management of risks irrespective of working patterns. This policy id available at all times through the intranet. Equality Area Social Deprivation Key Equalities Legislation / Policy (See summary sheet) Neighbourhood Renewal Strategy Tackling Health Inequalities Local Area Agreement Is this policy or service RELEVANT to this equality area? YES / NO No Assessment of Potential Impact: HIGH MEDIUM LOW NOT KNOWN positive negative (-) (+) Reasons for Assessment This policy is for employees and will have no impact on this equality target group in the way the policy is implemented. 30

APPENDIX 5 EMPLOYEE RECORD OF HAVING READ THE POLICY Title of Policy/Procedure: Maternity Risk Management Strategy I have read and understand the principles contained in the named Strategy. PRINT FULL NAME SIGNATURE DATE