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NUH clears backlog of Serious Incident investigations in maternity services

Nottingham University Hospitals Trust says it has almost entirely cleared its serious incidents backlog within maternity services.

The trust set itself a target in December 2022 to investigate the incidents which occurred before September 2022 – but this deadline was missed.

It then set a new deadline of 31 March.

Serious Incidents (SIs) are unexpected or unintended events that could cause NHS patients harm.

Of the ‘backlog’ of 61 incidents, as of March 30 two have not yet had investigations completed – one is being looked at by the HSIB (Healthcare Safety Investigation Branch) and another is on hold so the trust can meet the family involved in the case.

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Some of the 61 SI investigations dated back years. The oldest of the incidents happened in 2019 and another incident was in July 2021.

Maternity services at the trust have been declared ‘inadequate’ by health watchdogs.

The trust says it carries out a rapid review process within 72 hours of a serious incident occurring.

During January and February 2023, there were three new Serious Incidents (SIs) declared in Maternity Services but these are not part of the 61 in the ‘backlog’.

During the trust board meeting on March 30, Director of Midwifery Sharon Wallis said: “There has been a huge piece of work done by the team on Serious Incidents.

“It has been a really steep learning curve.

“We have virtually cleared the 61 SIs that we had. That has been a mammoth task for us and a massive achievement.

“We are now looking at the next phase of that sustainable approach.

“We have identified funding for investigators that will sit within the patient safety team and will be that resource specifically for maternity.”

Gemma Malin, Clinical Director for maternity, said as of March 3, there were three cases being investigated by HSIB (Healthcare Safety Investigation Branch).

HSIB investigates maternal deaths, neonatal deaths, stillbirths, or babies who require therapeutic cooling due to Hypoxic Ischemic Encephalopathy (HIE).

Ms Malin added: “As part of the SI process, a key focus has been making sure each of the investigations has a robust action plan.”

Gilbert George, a new member of the board who is Director of Corporate Governance, said: “We’ve seen a great deal of effort put in with regards to SIs and the tangible benefit of you doing that.

“I wanted to ask about the learning, are we seeing tangible improvements and outcomes as a result of the investigations that have been conducted?”

Ms Wallis responded: “Yes we are, we have fewer cases reported to HSIB (Healthcare Safety Investigation Branch).

“We are seeing a change in the themes.

“It has been a sprint and we recognise that we absolutely have to embed those learnings.

“When the team have taken a breath, then they will be able to pull those learnings together.”

Keith Girling, Medical Director, thanked the investigation team and says it has been a “herculean effort”.

He added: “The teams have literally been working night and day.”

Professor John Atherton, non-executive director, said: “We feel there has been huge improvement That doesn’t mean there’s not a long way to go.

“Triage has improved hugely, we are doing well with Ockdenden [actions required from the 2017 review].

“There is really good progress in those areas.

“There was a commitment to clear SIs this month and apart from two – one of which was external and one of which has rightly come back following communication with the patients involved, we got there.

“That is a huge move forward and I congratulate you on that.

“We still need to get to a place where we’ve got stability with SIs but we have cleared the backlog which is great.

“The learning from SIs, we feel is now being done very well with really good immediate learning and embedded learning.”

Michelle Rhodes, Chief Nurse at Nottingham University Hospitals NHS Trust, said:

“We have made significant progress reducing the backlog of serious incidents in maternity. We have completed all overdue investigations, with just two remaining that require more family input.

“We know that completing these investigations in a timely way is so important for our families and our staff to ensure that we learn and implement changes as soon as we can.”

The trust added that since September it has improved the way it communicates with families through meetings with those involved, the appointment of a dedicated family liaison matron and having a named contact to ensure that families are kept up to date on ongoing investigations.

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