The Maternity Governance Team work collaboratively to support the quality and safety agenda by ensuring that patient safety events are managed in line with local and national guidance. The maternity governance team also collate themes and trends to determine where quality improvements are required, support guideline changes, clinical audit and work with families and staff to improve the maternity service.
In relation to the review of patient safety events the maternity governance team responsibilities are as follows;
- Incident Notification and Initial Response
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- Receive Incident Reports: The team receive incidents via the Trust incident reporting system.
- Triage and Categorise: All reported incidents are reviewed and assessed daily to determine if further enquires are necessary to determine if harm has been caused. If the team cannot determine this, they will request a written response to be completed timely to enable any learning to be identified and proposal of next steps of a patient safety review. This may include an After Action Review (AAR) or a PSII review.
- Duty of Candour
- For any incidents where there seems to have been omissions in care written Duty of Candour is provided to the family.
- External Bodies Include:
MBRRACE
MNSI
LMNS
ICB
NHSE
Health and Safety Executive
Coroner
- Coordination and Oversight of the Patient safety review
If there has been a patient safety event which requires a further review of care to be undertaken such as an AAR or a PSII Review the maternity governance team will usually support the review by;
Identifying Leads, (except for MNSI cases) – this is usually an Obstetrician and Midwife but depends on the patient safety event
Offer support and guidance to the investigators.
Identify a family liaison officer to keep the family updated.
Review the written response and offer feedback to the investigators prior to its completion to enable changes to be made, prior to submission to the senior leadership team for sign off.
- Facilitation and Support for Staff
- Provide Guidance: Offer support to staff to write statements in a factual manner.
- Psychological Support: Arrange debrief sessions and provide details of how to access Trust health and wellbeing services counselling
- Statement Support: Provide guidance and support to those who are required to provide written statements and/or attend and MNSI interview. Work in collaboration with the Trust legal team to prepare staff for coronial inquests.
- Action Planning and Implementation
- Develop Recommendations: Based on investigation findings, the team collaborates with clinical leads to identify SMART actions.
- Monitor Progress: Once the report is finalised and actions agreed the maternity governance team are responsible for the monitoring and compliance of actions is achieved and keep records of the completed actions.
- Guidance Changes – The maternity governance team will work with guideline authors to update changes in guidance following a patient safety event
- Audit – The maternity governance team will (depends on local arrangements) ensure that any required audits following a patient safety event are completed and associated actions addressed as part of the audit cycle.
- Reporting and Communication
- Prepare Final Reports: Ensure that the final investigation report is completed and shared appropriately as per Trust process.
- Feedback to Families: Offer families the opportunity to receive the findings in a format that they choose. This can be a face-to-face meeting or providing them with a copy of the final report.
- Shared Learning:
- Local – Disseminate lessons learned throughout the maternity unit and the wider Trust using local tools such as safety briefings, newsletters, and /or training sessions.
- External – Reports may be required to be shared with external bodies such as (but not limited to) the ICB, LMNS, Coroner
In summary, the Maternity Governance Team is integral to ensuring that maternity care incidents are handled transparently, supportively, and effectively, with a focus on learning and improving patient safety.