The Role of the Maternity Governance Team
The Maternity Governance Team work collaboratively to support the qualit 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
- 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 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 Patient Safety Incident Investigation (PSII).
- Duty of Candour – For any incidents where omissions in care have been identified, written Duty of Candour is provided to the family.
- Referral to appropriate external bodies – Some incidents may meet the criteria for referral to external bodies, including those listed below.
MNSI – find out which cases are referred to MNSI by viewing their website: MNSI website
MBRRACE-UK – All eligible maternal deaths occurring during pregnancy or within 12 months of the end of pregnancy, and eligible perinatal deaths (including late fetal losses, stillbirths and neonatal deaths), must be reported to MBRRACE-UK in accordance with national reporting requirements. MBRRACE-UK also undertakes detailed confidential enquiries into selected cases to identify learning and improve the quality and safety of maternity and neonatal care.
Local Maternity and Neonatal System (LMNS)
Integrated Care Board (ICB)
NHS England
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 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 involved in the investigation process.
- 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 an 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.