Escalation Policy - Maternity

Escalation Policy - Maternity Version 4 Lead Person(s): Andrew Tapp, Care Group Medical Director Cathy Smith, Head of Midwifery and Care Group Director Care Group: Women and Children s First Implemented: June 2010 This Version Implemented: 1 st December 2015 Planned Full Review: December 2018 Keywords: Staffing levels, midwifery; Escalation, staffing levels Written by: Anthea Gregory-Page, Deputy Head of Midwifery Jan Latham, Senior Midwife for Consultant and In Patient Services Clinical Risk Co-ordinator (2010) Revisions By: Maggie Kennerley, Lead Midwife Angela Hughes, Assurance lead Paula Williams, Guideline Midwife Consultation: Andrew Tapp, Care Group Medical Director Cathy Smith, Head of Midwifery and Care Group Director, Anthea Gregory Page, Deputy Head of Midwifery Comments: References to SaTH Guidelines in the text pertain to the latest version of the Guideline on the intranet. Printed copies may not be the most up to date version. To be read in conjunction with: Neonatal Escalation Guideline For Triennial Review Version Implementation History Ratified By Full Review Date Date 1 June 2010 New Maternity Governance March 2013 1.1 3 rd October 2011 New structure/ title changes GC Authorisation October 2014 2 15 th January 2013 Escalation for MLU and Escalation forms & Maternity Guidelines Group (MGG) October 2014 CNST requirements Maternity Governance 2.1 20 th September 2013 Addition of Appendix 2b GC Authorisation October 2014 3 30 th September, 2014 Full Review / Revision due to reconfiguration GC Authorisation Extraordinary Approval September 2017 4 1 st December 2015 Full Review in line with national guidance MGG Maternity Governance December 2018 Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 1 of 32

Appendices Appendix 1: Red Flag events Appendix 2 Maternity Escalation flowchart Appendix 3 Midwife Led Units Safe Staffing levels Appendix 4: Maternity Escalation Form Appendix 5: Closure of Maternity Beds, Ward, Department or Unit Appendix 6: Re-opening of the Unit Appendix 7: Letter to parents Appendix 8a-e: Acuity Tools Appendix 9 Hospital Contact Numbers Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 2 of 32

1.0 Introduction 1.1 This escalation policy is specific to the Maternity Units within Shrewsbury and Telford Hospital NHS Trust (SATH), which include the Consultant Units and all peripheral Units within the Trust. This must be read in conjunction with the Neonatal Escalation Policy SaTH, the Strategy for Safe Staffing- Midwifery Guideline, the SaTH On-call policy, and the Labour Ward Staffing Guideline. 1.2 Every effort will be made to accommodate the women booked within Shropshire for maternity care to be cared for within SATH. 1.3 Appropriate staffing levels and skill mix across all Midwifery, Nursing, Support Staff, Obstetricians and Anaesthetists are essential for providing a safe maternity service. 1.4 Closure of the Unit would have major implications for all patients booked for care, neighbouring hospitals and the neonatal services. The decision to close is a final resort with the decision taken by Trust / Centre Board, Head of Midwifery,, Care Group Medical Director and Consultant Obstetrician, in consultation with the Supervisor of Midwives. 1.5 Closure will only be considered when all other potential solutions are exhausted. However, in the rare event of the closure of the Maternity Unit it is paramount that we have clear safe alternative arrangements for the care of mothers and babies. This document should be read in conjunction with the West Midlands Local Supervising Authority The Management of Maternity Beds (2008) see Appendix 1. 1.6 This guidance has been reviewed against NICE safe midwifery staffing (2015) guidance and incorporates the recommendations made. 2.0 Aim(s) The purpose and intention of this document is to provide staff within the multidisciplinary team with guidance on how to manage beds and staffing levels to ensure services are maintained during times of high activity or staffing shortfall within the Consultant Unit and all peripheral Units within Maternity. 3.0 Objectives 3.1 Provision of guidance for staff on routine bed management within the Consultant Unit and all peripheral Units within Maternity. 3.2 Provision of guidance for staff on crisis bed management within the Consultant Unit and all peripheral Units within Maternity. 3.3 Provision of guidance for staff on unit closure within the Consultant Unit and the relevent peripheral Units within SaTH Maternity. 3.4 To provide guidance for staff on trigger systems (red flags) and when to escalate short and long term staffing to Lead Midwives, Maternity Governance or Centre Board. 3.5 To identify the resources required to evaluate the effectiveness of service provision and in order to meet these needs, if required, facilitate a service restructure 4.0 Definitions 4.1 Factors precipitating suspension of a Maternity Unit 1. Insufficient Midwives or Doctors 2. Inappropriate experience/skill mix to provide suitable care 3. No available beds 4. Infection of clinical areas advised by microbiologist 5. Major security alert/incident, or environmental factors such as power failure or flooding 6. NNU Escalation at Red + with no apparent resolution. 7. Red Flags identified 4.2 Green routine bed management procedures The Maternity Unit has no anticipated concerns that will prohibit admissions. 4.3 Amber crisis bed management procedures The Maternity Unit has recognised factors and instigated contingency plans. 4.4 Red restriction of admissions to obstetric clients/closure of unit After following amber bed management procedures a Unit or Department remains unable to resolve factors. Additional management is required and the Unit may have no choice but to suspend activity until the area can once again be fully operational. Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 3 of 32

4.5 Red + - Consultant Unit is unable to address factors 4, 5 or 6 which are present in the Unit. 4.6 Intrapartum score card a tool for monitoring and improving patient safety in maternity units. 4.7 Red Flag is a warning sign that something maybe wrong with midwifery staffing (NICE 2015) (see Appendix 2 for midwifery red flag events) 4.8 Delay in care or treatment- where there has been significant delay in provision of care, which has affected the quality of care, safety or clinical outcome 4.9 Ward acuity tool is a traffic light system used to risk assess, monitor activity levels and identify red flags. 4.10 Board round a multidisciplinary review, led by the consultant on call, of patients on the consultant labour, antenatal and postnatal wards and neonatal unit activity. 4.11 Maternity Escalation Alert Form (Appendix 4) enables an appraisal of SaTH maternity services and documents the action taken when amber or red escalation invoked 4.12 Normal working hours 9am- 5pm Monday to Friday. Excluding bank holidays. 4.13 Outsdie Normal working hours 5pm-9am Monday- Friday, weekends and bank holidays. 5.0 Process see also Maternity Escalation Flowchart (Appendix 3) Bed management is reviewed within SaTH maternity services as a minimum daily, using the 08.30 board round (refer to section 4.10) during this process all activity is reviewed across the services and contingency plans are put in place to address high volumes of activity/acuity and concerns are escalated. Midwives are responsible for reviewing the provision of care which includes staffing levels and service provision. Ward activity is recorded using ward acuity tools, which incorporate red flags, by either the designated lead clinical midwife or ward manager and recorded on activity log at the change of shift or time of escalation. (See appendix 9a 9b 9c 9d) If it becomes apparent that the issues are not being resolved by local ward action, the delivery suite co-ordinator or lead Midwife/Deputy Head of Midwifery (normal working hours hours) or delivery suite co-ordinator/ on call manager (outside normal working hours) will be informed. They will provide guidance and support to help address the issue/s. Once escalated, if issues can not be resolved an Maternity Escalation Alert Form (Appendix 4). will be commenced by the person leading the escalation to capture the issues, deficits identified and if in relation to staffing, areas where staff can be relocated from/to Outside of normal working hours the Maternity Escalation Alert Form will be completed by either the delivery suite co-ordinator or on call manager. The ward acuity tools will indicate either of the following statuses and actions taken accordingly 5.1 Green routine bed management procedures (no factors) The Maternity Unit has sufficient designated beds to fulfil the contracted elective and emergency activity. Day to day management of beds in hours is the responsibility of the Ward/Unit Manager. Implementation of maximum efficiency in bed usage is encouraged. Close involvement of the senior clinicians is key to efficient administration and discharge practice. Each area is expected to contain their activity within bed availability; therefore if beds are closed for any reason, activity should be adjusted accordingly. Out of hours and at weekends, routine bed management is the responsibility of the delivery suite co-ordinator and the manager on-call. 5.2 Amber Bed management procedures Alert ward managers/ Lead Midwife (in normal working hours) or delivery suite Coordinator/ Women s and Children s on call Manager (outside normal working hours hours) to assist in undertaking amber bed management procedures. Consider use of all available Midwives onsite. Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 4 of 32

Consider temporary redeployment of staff from other Departments or outlying areas to facilitate bed management procedures and ensure patient safety during crisis period. Alert On-call Consultant, ensure they or their Middle Grade undertake additional wards rounds in all areas to review status of inpatients. On-call Consultant or their Middle Grade will expedite clients discharge where possible. Alert relevant Midwives/Ward Managers in other Units/areas. Explore the possibility of identifying additional bed and theatre capacity in liaison with the Clinical Site Managers, the Consultant on-call and on-call managers. Alert Neonatologist, including Consultant in order to review babies to expedite discharge where possible. Designate staff to help with discharge procedures. Consultant on-call to review all elective admissions. The Consultant on-call or their Middle Grade should consider deferring elective caesarean sections and induction of labours if at all possible. Women who are affected by the bed management procedures are kept fully informed during crisis bed management. Documentation should reflect any discussions with the women. Consider transfer of women to peripheral units with capacity.(sath or external). Consider transfer of patients with early pregnancy complications to gynaecology. 5.3 Red Restriction of Activity on consultant unit or MLU Amber bed management will continue when red has been identified on a ward(s) acquity tool, however if this does not resolve the issues the following will be undertaken: Ensure Ward Managers/ Lead Midwive(s) (in normal working hours) or delivery suite Co-ordinator/ Women s and Children s on call Manager (outside normal working hours hours) Desist all unnecessary activity Review induction of labours, with a view to postpone Transfer high risk women to other consultant units. Redeploy all midwives, including non clinical, to the areas of high activity. Inform the deputy head of Midwifery/Head of Midwifery. Escalation management meeting called Either the lead midwife or, the manager on-call (if out of hours) with support from a Supervisor of Midwives (where appropriate) will co-ordinate the procedure for diverting some maternity activity. Diversion of clients should be carried out on an individual basis following consultation with the On Call Consultant Obstetrician and/or Consultant Neonatologist as appropriate. If amber and red bed management procedures have not resolved the bed crisis, the Lead Midwife or manager on-call (out of hours) will liaise with the Deputy Head of Midwifery/ Head of Midwifery when considering the decision to suspend the Maternity Services. Only the Deputy Head of Midwifery, Head of Midwifery or Care Group Medical Director can make the decision to close beds/wards/departments or Units. If closure is required, Individuals identified on the closure of a Maternity Unit Form (see Appendix 5) will be informed. Suspension of maternity services may involve the closure of beds, ward/s, departments/s or unit/s and may not always be in relation to staffing issues. Other possible reasons for closure will include: Lack of essential resources e.g. electrical/water utilities Equipment failure e.g. lifts, Infection in the clinical area, where closure has been advised by the microbiologist. Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 5 of 32

In the event of a major security incident. If the decision is made to suspend Maternity services the person leading the closure will ensure that: The closure of Maternity Beds, Ward, Department or Unit actions and communication list (Appendix 5) is completed Staff working at the time of the suspension of services will be fully informed of the suspension status. The contingency plans will be outlined on the delivery suite board and continually updated until the suspension is lifted. Explore the possibility of identifying additional bed and theatre capacity in liaison with the Clinical Site Managers, the Consultant on-call and On-call Managers. Arrangements are made with neighbouring Maternity Units to accept women in labour always aiming to take into consideration where women live. The Consultant Neonatologist and Lead Nurse for the Neonatal Unit (NNU) are informed. Ambulance Control for both the West Midlands and Powys regions are informed. Women who have not contacted the Maternity Unit prior to their arrival will be assessed and arrangements made for their safe transfer via paramedic ambulance to a receiving Unit. Each woman requiring admission has confirmation of the arrangements for transfer and details of the hospital location. In addition, she will be reminded to take her pregnancy health record with her. The Trust Executive is informed by Lead Midwife or Maternity On-call Manager. Switchboard is informed. The Trust Communication Team is informed. Re-opening the Maternity Unit The Lead Midwife or manager on-call will reverse the suspension of services process when the factors that precipitated the closure are resolved. The communication checklist (Re-opening of a Maternity Unit form Appendix 6) will be used to ensure that all relevant personnel are informed of the re-opening. A letter will be sent to all women who were directed to other Units as a result of the closure to apologise for the inconvenience caused (Appendix 7). Restriction of Activity on the Neonatal Unit If the Neonatal Unit is on a category red plus, an escalation planning meeting will be called to identify priorities and to assist this process, refer to Neonatal Escalation Guideline. Role of the Supervisor of Midwives (SOM) during periods of escalation The primary function of the SOM at these times is the continued protection of the public and the SOM will support midwives to ensure that midwifery practice occurs in the safest possible environment. Escalation will be co-ordinated by the Lead midwife/on call manager with support/input from the SOM. Addressing Staffing Shortfalls Staff shortage can occur at times of unusually high workload or high dependency, at times of increased staff sickness levels, when there are unfilled vacancies or during adverse weather events. Immediate, time critical management of staffing shortage. This may be due to a period of high activity on Delivery Suite or more than one home birth attendance in one outlying area. Ward/Unit manager will alert the Lead Midwife for the area during business hours or manager on-call out of hours. Consider redeploying staff, including specialist midwives, from other wards or departments. Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 6 of 32

Consider redeploying staff from peripheral Midwife Led Units if there are no women in labour. Consider redeploying staff to assist MLU s or community. Consider asking staff to extend their shift hours or to come in early for their next shift. Consider using the staff texting system to send out an SOS message for assistance. Consider calling in the MLU/Community on-call staff to staff the unit, unit midwife to be redeployed for a maximum of four hours call-out. Unit manager, Lead Midwife or Manager on-call to liaise with Consultant on-call and delay all non-essential inductions and elective caesarean sections. If this does not resolve the problem, manager or manager on-call to escalate to Deputy Head of Midwifery/Head of Midwifery. 5.6.1 Short term staffing shortage midwifery, nursing or support staff In the event of short term staffing shortages the Ward Manager/delivery suite coordinator or the Lead Midwife for that area or Unit during day time hours or the delivery suite co-ordinator or manager on-call out of hours will take into consideration the following: Review off duty rota s for all areas and consider redeploying staff from other wards, departments or peripheral Midwife Led Units. Review planned study leave/annual leave and re-schedule. Review of elective work inductions, caesarean sections with the Consultant on-call. Review ward areas and peripheral units and expedite discharges where possible. Review all non urgent work, community and parent education. Liaise with Consultant on-call and consider cancellation of any non-urgent activities. Assess overall skill mix of midwifery, nursing and support staff and utilise appropriately. The delivery suite co-ordinator or Lead Midwife will contact: Antenatal Clinics and peripheral Midwife Led Units to ascertain if staff are available to cover on a short term basis. Part time staff who have indicated that they would be willing to work additional hours. Bank staff. During exceptional times, full time staff may be requested to work overtime hours (including those on annual leave). To ensure patient safety and safe staffing levels, staff must be prepared to move to another area or Unit when requested to do so by the Lead Midwife, the delivery suite co-ordinator or the manager on-call. (This could be from MLU to the consultant unit or the consultant unit to an MLU) Short term staffing shortage medical staffing If medical staff are unwell relevant personnel will be contacted, refer to staffing guideline for obstetricians for contact details. Process On receipt of notification in hours, the rota co-ordinator reallocates medical staff to ensure continuous emergency cover to the Labour Ward. If the rota can be adequately filled with in-house locums and cross cover of clinical activity, no external aid is sought. If the rota cannot be filled then agency locums are appointed to ensure smooth running of all aspects of the department, but primarily 24/7 cover of the Labour Ward. Out of hours the onsite manager and the Consultant on-call identifies the impact of the deficit on the department. If there is going to be or is an immediate absence on the 24/7 Labour Ward cover rota, all permanent members of staff are contacted to see if they are able to Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 7 of 32

supply short term locum cover. If they are unable to supply short term locum cover, then agency assistance is sought. The Consultant on-call and the Ward Manager/Lead Midwife work together to understand the safety of continuing acute obstetric practice in such circumstances and assistance is sought from surrounding Obstetric Units. Other resident medical rotas are also contacted to see if some of the emergency activity of the medical staff can be undertaken by alternative medical practitioners in a safe manner. 5.6.2 Ongoing staffing shortfalls When the above measures have not resolved staffing issues for Midwives, nursing, support staff or medical staff, the following should be made aware of the situation: Lead Midwife for that area/midwife Led Unit Deputy Head of Midwifery/Head of Midwifery Care Group Medical Director The Ward Manager/Lead Midwife in hours or the manager on-call out of hours will ensure the following: Review of all areas to judge workload and dependency Contact part-time staff who may work extra hours Contact specialist and Lead Midwives to work clinically Contact full time staff to work overtime hours Consider redeploying staff from peripheral units Consider redeploying staff to assist community or peripheral units Consider closure of peripheral units on a temporary basis Review of all planned study leave/annual leave and reschedule Cancellation of all non-urgent activities If any of the Maternity Units continues to be unable to address staffing shortfalls the Unit has no choice but to suspend activity until the unit can once again be fully operational. 5.6.3 Long term staffing shortfalls midwifery, nursing and support staff When short term or ongoing staff shortfalls have not been resolved it is imperative that the Lead Midwives, the Head of Midwifery and the Centre Chief are made aware of the situation and will risk assess and if necessary place onto risk Register. Please refer to Safe Staffing Levels for Midwifery, Nursing and Support Staff for details of contingency and business planning for medium and long term staffing shortfalls and Safe Staffing Levels for Obstetricians. The coordination of ward acuity forms rests with the ward manager who will report this activity to the maternity management meetings. Any other concerns will be escalated to maternity Governance. 6.0 Training 6.1 New Midwives and medical staff will be informed about the process for accessing guidelines during their induction. 6.2 New or updated guidelines will be disseminated as per the Guideline, Protocol and Policy Development Framework Maternity (060) 7.0 Monitoring/Audit Acuity forms will be monitored through maternity management meetings. If escalation tracker forms are required in an area 3 times or more in one month for 3 consecutive months then these trends will be escalated to Maternity Governance. Decision for Audit/Monitoring The requirement to undertake audit/monitoring will be identified via legal cases, high risk case review, serious incidents, and where there is trends in incident reporting. Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 8 of 32

8.0 References Department of Health. (2007). Maternity Matters: Choice, access and continuity of care in a safe service. London: COI. Available at: www.dh.gov.uk NHS Litigation Authority Clinical Negligence Scheme for Trusts (2009). Maternity Clinical Risk Management Standards (Version 2 2009/10). Available at: www.nhsla.com NICE (2015) NICE Safe Midwifery Staffing, NICE Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press. Available at: www.rcog.org.uk Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College of Midwives, Royal College of Paediatrics and Child Health. (2008). Standards for Maternity Care: Report of a Working Party. London: RCOG Press. Available at: www.rcog.org.uk Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 9 of 32

Appendix 1 Midwifery Red Flag events Agreed locally by the West Midlands Heads of Midwifery Delay in suturing of more than 60 minutes Delay in Triage of more than 30 minutes Delay in commencing Induction of Labour of more than 2 hours Delay in category 1 caesarean section of more than 30 minutes Unable to achieve one to one care in labour Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 10 of 32

Appendix 2- Maternity Escalation Flowchart Ward or Unit acuity tool Completed by ward manager or designated midwife in charge of shift at change of shift. Indicating GREEN, AMBER or RED status or red flag identified Unable to resolve issue Inform lead Midwife or Delivery Suite Coordinator Datix completed (followed up at governance) Unable to resolve issue Escalation meeting called (Daytime hours) by lead midwife or Deputy HOM On call manager informed and may need to attend and co-ordinate escalation Re-evaluate using ward acuity tool and escalation Alert form Local action taken Issue resolved following involvement of ward manager or delivery suite co-ordinator Escalation Alert form completed by person leading escalation or labour suite cocoordinator/on call manager Issues resolved e.g. by redeployment of staff returning area to AMBER/GREEN status Local action taken to address shortfalls. Area/ward status returning to AMBER/GREEN In discussion with the Deputy HOM or HOM, evaluate if closure of the unit is required. (See section of guideline) Decision made to close beds/ward/ department/unit Complete closure of maternity beds/ward/ department/unit form and relevant personnel informed Person responsible- In normal working hours Out side normal working hours Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 11 of 32

Appendix 3 Midwife Led Units Safe Staffing Levels RSH MLU Midwives WSA Other Day Shift 12 ½ hours 2 1 Includes 30 min handover Night Shift 12 ½ hours 1 1 Includes 30 min handover Oswesrty MLU Midwives WSA Other Day shift 12 ½ hours 1 1 Includes 30 min handover Night Shift12 ½hours 1 1 Includes 30 min handover Ludlow MLU Midwives WSA Other Day shift 12 ½ hours 1 1 Includes 30 min handover. Early and late shifts at weekends Night Shift12 ½hours 1 1 Includes 30 min handover Bridgnorth MLU Midwives WSA Other Day shift 12 ½ hours 1 1 Includes 30 min handover Night shift 12 ½ hours 1 1 Includes 30 min handover Wrekin MLU Midwives WSA Other Day shift 12 ½ hours 2 1 Includes 30 min handover Night shift 12 ½ hours 2 1 Includes 30 min handover Consultant Unit Safe Staffing Levels Delivery Suite Coordinator Midwives WSA Early 1 6 3 Theatre List Days 2 Tues, Weds & Thurs Late 1 6 3 Night 1 6 3 Antenatal Ward Midwives WSA Other Day Shift 12 ½ hour 3 2 Includes 30 min handover Night shift 12 ½ hour 3 2 Includes 30 min handover Postnatal Ward Midwives WSA Other Day shift 12 ½ hours 3 3 Includes 30 min handover Night Shift 12 ½ hours 3 2 Includes 30 min handover Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 12 of 32

Day Assessment Safe Staffing Levels RSH - MLU Covered by Midwives working on the MLU PRH - WANDA Midwives WSA Other 09.00-21.30 daily 2 1 Ward Clerk 4 days per week. Antenatal Clinic Safe Staffing Levels RSH Midwives WSA Other Weekday 1 3 Triage Midwife 5/7 Wrekin Midwives WSA Other Early weekday 2 2 Triage Midwife 5/7 9-5 weekday 1 or 2 depending on clinic 2 or 3 depending on number of midwives Oswestry MLU Midwives WSA Other Monday & Thursdays 1 0 USS clinic on Fridays (WSA -1) Scanning Safe Staffing Levels RSH Midwives WSA Other Weekday 4 0 WSA 3/7 Weekend 1 0 PRH Midwives WSA Other Weekday 2 0 WSA 3/7 Weekend 1 0 Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 13 of 32

Midwifery Community Teams Safe Staffing Levels Community Team Weekday Cover Weekend Cover RSH 5/7 +/- TIM 3/4 Midwives Oswestry 1 1 Ludlow 1 0.27 Returns to unit following community visits Night Cover Additional for clinic cover Extra Midwife on Monday Bridgnorth 1 1 Extra Midwife on Tuesday Wednesday and Thursday Wrekin 8/9 4 Depends on number of antenatal clinics on the day (some days have 9 community antenatal clinics) Whitchurch 1 1 1 extra midwife 3 days a week Market Drayton 1 1 1 extra midwife 3 days a week WSA Community Teams Safe Staffing Levels Community Weekday Cover Weekend Night Cover Team Cover RSH 1 0 0 Oswestry 0 0 0 Ludlow 1 on a Monday 0 0 Bridgnorth 0 0 0 Wrekin 1/2 0 0 Whitchurch 1 (3 days a 0 0 week) Market Drayton 1 (3 days a week) 0 0 Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 14 of 32

Appendix 4 Maternity Escalation Alert Form Date: Time: (to be completed by lead midwife/ward manager/labour ward co-ordinator/on call manager) Area Initiating Escalation: Reason: Name of Staff Member: Ward/Area No of Beds No of women No of beds available Normal staffing levels met (please circle) Number of Midwives on call Identified deficit & reason Current issues /red flags RED AMBER GREEN Antenatal Ward (Bereavement Suite) 18 (1) Y / N Consultant Delivery Suite (Theatres) 13 (2) Y / N Consultant Postnatal Ward 23 RSH MLU/Community/ DAU (labour rooms) (overflow PN beds) Wrekin MLU/Community /DAU (labour rooms) Oswestry MLU/Community (labour room) Bridgnorth MLU/ Community (birth rooms) Ludlow MLU/ Community (labour room) 10 (3) (4) 13 (4) 6 (2) 4 (2) 7 (1) NNU 22 Day Assessment Unit Market Drayton Whitchurch Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 15 of 32

Pending Pressures based on risk assessment (including anticipated premature deliveries): Actions Required: Communication Name of person informed Time informed 1. Lead Midwife on duty informed yes / no 2. On Call Manager informed yes / no 3. Deputy Head of midwifery informed yes / no 4. Head of Midwifery Informed yes / no Closure of beds/ward/department/ unit required: Yes / No (If yes complete closure form) Print name and designation: Signature: Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 16 of 32

Appendix 5 Closure of Maternity Beds, Ward, Department or Unit Actions taken prior to closure YES NO NA Review off duty rotas for all areas Contact available staff (clinical and non clinical) Text alerts sent to staff Review of elective work and further ward rounds Liaise with consultant on call and cancellation of any non urgent activities Assess overall skill mix of midwifery, nursing and support staff/obstetric cover Contact antenatal clinic and peripheral units to ascertain staff available for cover Consider cancellation of study leave/ Annual Leave/non-essential leave (Supervision, Unison) Communication List Facility affected: Name of Manager authorising closure: Date of closure: Time of closure: Reason(s) for closure: Unit staff informed Other areas W&C Management (daytime) W&C On-call Manager (out of hours) Deputy Head of Midwifery Head of Midwifery/Care Group Director Care Group Medical Director Trust Executive Other neighbouring units. Clinical Site Manager (bleep 886) Consultants on-call West Midlands Ambulance Control(01384 215511) (01743 356331) Powys Ambulance Control Centre (01633 626096) Informed? (yes/no) How? Person informed By whom Action/comments Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 17 of 32

Hospital Switchboard. PRH, RSH & unit affected. Trust Communication Team Supervisor Of Midwives on call. CEO (Information only via Deputy HOM or HOM) CCG (Information only via Deputy HOM or HOM) Other People informed Signature: Designation Date: Datix Number Patients affected during unit closure Name and Unit number Date and time of transfer Site transferred to Clinical over view Information to Patient/Family. Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 18 of 32

Include details of any complaints expressed or media coverage at the time of closure: Actions Taken During closure Date /Time What was done By who Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 19 of 32

Appendix 6- Re-opening of a Maternity Unit - Communication List Name of Unit for re-opening: Date of Re-opening: Name of Manager authorising re-opening: Time of re-opening: Reasons for closure: Unit Staff Informed Other Areas Informed Yes / No Person Informed By whom? W&C Management (Day time) W&C On-call Manager (Out of Hours) Deputy Head of Midwifery Head of Midwifery Care Group Medical Director Supervisor of Midwives on call Other Neighbouring / Regional Units Clinical Site Manager (Bleep 886) Consultants on call West Midlands Ambulance Control (01384 215511) (01743 356331) Powys Ambulance Control (01633 626096) Switchboard RSH, PRH & affected Unit Trust Communication Team CEO (Information only via Deputy HOM or HOM) CCG (Information only via Deputy HOM or HOM) Other People Informed Confirmed length of closure: Signature: Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 20 of 32

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Appendix 7 Princess Royal Hospital Grainger Drive TF1 6TF 01952 641222 ext 5995 Date Dear I would like to apologise that you had to be referred to another Maternity Unit on (insert date) owing to the temporary closure of the Maternity Unit at (insert which hospital). As I believed you were informed at the time, this was due to (insert reason/s here) Please be assured that the health and safety of both your baby and yourself was our prime concern when the decision to refer you to another hospital was made. A decision to close the Maternity Unit is always made as a last resort, but we understand how stressful this late change must have been for you. We would like to take his opportunity to offer you further explanation if you feel you should need it. This can be done in a number of ways, i.e. in a meeting or by telephone. If you would like to take up this opportunity, please do not hesitate to contact my PA, Rachel Hanmer, on the above telephone number. Yours sincerely Mrs Cathy Smith Head of Midwifery Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 22 of 32

Appendix 8a Acuity Tool- All Maternity Areas GREEN AMBER RED RED + Level 2 Level 3 Maternity Units Operational Maternity Services under extreme However experiencing some pressure pressures Business continuity threatened Level 1 Maternity Units Fully Operational No major issues Staffing levels normal Short to medium term staff shortages affecting the Units ability to provide specific services Medical staffing levels normal Elective surgery lists proceeding as scheduled. No significant delays. Sufficient capacity to carry out emergency Instigation of contingency plans for yellow alert has failed to resolve capacity issues Staffing shortfall identified All beds in Maternity Unit are full including those utilised for low risk women on Bay C on AN ward and following further Consultant Ward rounds The level of bed occupancy has reached crisis point within one or more Units Level of activity actual and anticipated is beyond the bed capacity available caesarean sections Delivery beds available Limited capacity in antenatal and postnatal wards. Additional capacity created in Bay E MLU for low risk women Postnatal ward activity normal levels Capacity available on antenatal and or postnatal wards Potential closure of peripheral Units to address staffing issues Potential postponement of elective caesarean sections and induction of labour Potential diversion of clients to peripheral units Neonatal Unit Escalation Level RED resulting in transfer of neonates <34 weeks gestation Unresolved several short, medium and long term staff shortages impacting on safe service of either midwifery, nursing, support or medical staff Suspension/diversion of elective caesarean section service Suspension/diversion of induction of labour service Suspension of one MLU Major incident within Maternity Services or within the Trust affecting business continuity Neonatal Unit Escalation Level RED + with options for resolution Infection or equipment failure Isolate to one area/unit Suspension of Consultant Unit Services Instigation of contingency plans for red alert has failed to resolve capacity issues within the Consultant Unit Service wide infection Consultant Unit service wide equipment failure or major incident Neonatal Unit Escalation Level RED+ with no resolution Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 23 of 32

Appendix 8b Acuity Tool- Delivery Suite GREEN AMBER RED Level 1 Level 2 Delivery Suite Delivery Suite Operational Fully Operational However experiencing some pressures No major issues NNU has capacity for admissions, no requirement for in-utero transfers out. NNU limited capacity. There maybe the requirement for in-utero transfer out to regional units All women in labour receiving one to one care. Midwives case load more than one women in labour but no safety issues The co-ordinator is super numerary Co-ordinator taking admissions of nonlabouring/ early labouring women but still able to safely manage the ward Day assessment able to take all admissions Women awaiting induction of labour likely to be transferred within 4-6 hours Day assessment capacity limited for next 4 hours, so emergency cases will attend delivery suite. Women awaiting IOL unlikely to be transferred in the next 4-6 hours Level 3 Delivery suite under extreme pressure Business continuity threatened NNU has no capacity. In-utero transfer pending More women than midwives can care for safely Co-ordinator is caring for a woman and unable to co-ordinate delivery suite safely. No day assessment appointments available for the rest of the shift. Admissions likely. Women waiting more than 8 hours to be transferred to the delivery suite to continue IOL process Rooms available for admissions Only 1 room available on delivery suite No available delivery rooms Delivery suite fully staffed to template Delivery suite midwifery staff reduced by 1. i.e. sickness Midwifery staffing reduced by 2 members of staff No LSCS outside of elective list Cat 3 LSCS, delivery staff providing some support. Emergency LSCS requires more staff than available. RED FLAGS 1) Delay in suturing more than 30 minutes 2) Delay in category 1 caesarean section 5 Green = Normal Care on Delivery Suite 3 Amber = Need to consider escalation and potential staff who could be brought in 1 Red = Escalate to ward manager/lead Midwife or Manager on call. Ward Acuity/Activity Log- Delivery Suite Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 24 of 32

TO BE COMPLETED AT EACH HAND OVER OR AT TIMES OF HIGH ACTIVITY Date Time Escalation Level Red Flags Comments Appendix 8c Acuity Tool- Midwife Led Unit GREEN AMBER RED Level 2 Maternity Units Operational Level 1 Maternity Units Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 25 of 32 Level 3 Maternity Services under extreme pressure

Fully Operational However experiencing some pressures No major issues Staffing levels normal Short to medium staff shortages affecting the Units ability to provide specific services (e.g. antenatal appointments and home births) Delivery bed available On-call midwife required to assist on MLU or another unit (excluding 2 nd MW for delivery, Pethidine administration or home birth) Postnatal ward activity normal Level of bed occupancy has reached capacity Midwife not able to provide continuous one-toone care in labour but no safety issues Capacity to undertake normal community and unit Antenatal and postnatal activity diverted or activity delayed/unable to receive transfers from the consultant unit. On-call cover available Women requiring early discharge due to high activity on the unit. Delayed acceptance of postnatal transfers from consultant unit Additional staffing requested (from off duty or other units) or Ward manger required to work clinically due to high activity. RED FLAGS 1)Delay in suturing more than 60 minutes 2) Delay in Triage more than 30 minutes Business continuity threatened Infection resulting in advice to close Major security/incident or equipment failure Instigation of contingency plans has failed to avert temporary suspension of intrapartum services All beds in the Unit are full including labour beds Diversion of all admissions including labour ward admissions to alternative MLU/ CU Unable to offer home birth service More women in labour than midwives can care for safely 5 Green = Normal Care on MLU 2 Amber = Need to consider escalation and potential staff who could be brought in 1 Red = Escalate to ward manager/lead Midwife or Manager on call. Ward Acuity/Activity Log- MLU TO BE COMPLETED AT EACH HAND OVER OR AT TIMES OF HIGH ACTIVITY Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 26 of 32

Date Time Escalation Level Red Flags Comments Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 27 of 32

Appendix 8d Acuity Tool- Antenatal Ward Green Amber Red Level 1 Antenatal Ward Fully Operational No issues Level 2 Antenatal Ward Operational Experiencing some pressures Staffing levels normal Staffing levels reduced, no safety issues identified Beds available for admissions In sufficient beds available to facilitate flow through the consultant unit. Acuity: No concerns, no one-one care required Acuity: Bereavement or high risk woman requiring one-one care/ monitoring/elevated MEWS Open for out of county in-utero transfers in Case by case discussion with delivery suite coordinator and consultant obstetrician. RED FLAG- 1) Delay of 2 hours or more between admission for induction and beginning of process Level 3 Antenatal ward under extreme pressure Business continuity threatened Staffing levels reduced, safety issues identified No beds available for emergency admissions. Acuity: More than one High risk woman/ bereavement requiring one-one care. Closed to transfers in. Green = Normal service on Antenatal Ward 2 Amber = Need to inform Ward Manager/Delivery Suite Co-ordinator 1 Red = Activate Escalation Policy Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 28 of 32

Ward Acuity/Activity Log- Antenatal Ward TO BE COMPLETED AT EACH HAND OVER OR AT TIMES OF HIGH ACTIVITY Date Time Escalation Level Red Flags No of IOL in progress No of admissions today Comments Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 29 of 32

Appendix 8e Acuity Tool- Postnatal Ward Green Amber Red Level 1 Postnatal Ward Fully Operational No issues Level 2 Postnatal Ward Operational Experiencing some pressures Staffing levels normal Staffing levels reduced due to redeployment to other areas/ transfers out of area or sickness Beds available for admissions In sufficient beds available to facilitate flow through the consultant unit. Acuity: No concerns, no one-one care Acuity: High risk woman requiring one-one required care/ monitoring. Unable to perform required frequency of observations required for Mother/baby or both. Potential Patient safety compromise. Green = Normal service on Postnatal Ward 2 Amber = Need to inform Ward Manager/Delivery Suite Co-ordinator 1 Red = Activate Escalation Policy Level 3 Postnatal ward under extreme pressure Business continuity threatened Staffing levels reduced due to redeployment to other areas or sickness. No beds available. Acuity: More than one High risk woman requiring one-one care/monitoring. Unable to perform required frequency of observations required for Mother and baby or both. Patient safety compromised. Ward Acuity/Activity Log- Postnatal ward Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 30 of 32

TO BE COMPLETED AT EACH HAND OVER OR AT TIMES OF HIGH ACTIVITY Date Time Escalation Level No of patients on IV ABX No of babies having NEWS/TC observation s No of readmission s today Comments Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 31 of 32

Appendix 9 Hospital Contact Numbers Alder Hey Hospital 8092 Birmingham Children s Hospital 8174 Birmingham Women s Hospital 8172 Birmingham Heartlands Hospital 8178 City Hospital (Birmingham) 8177 Sandwell and West Birmingham Hospital Wolverhampton New Cross Hospital 0121 507 4703 hospitals to inform in the event of a unit closure 8123 County Hospital Stoke 8307 Stafford General Hospital 8307 University Hospital North Staffordshire Wrexham Maelor Hospital The County Hospital, Wye Valley NHS Trust (Hereford) Powys Midwives 8133 01978 725020 01432 355 444 Escalation Policy Maternity v3 (042) Sept 2014 Sept 2017 Page 32 of 32