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Regional perinatal clinical governance group

Who we are

This is a regional forum established in February 2018 whose membership represents and engages with a wide group of stakeholders who constitute a balanced and strategic group of experts involved in the day to day running of the governance network. Members are governance leads for obstetric, midwifery and neonatal departments within their organisations.  Partner organisations are:

The model is based on professionals working together across professional, organisational and geographical boundaries to promote leadership for a safety culture and carry out investigations with honesty and learning when things go wrong. The national drive to have user representation to ensure the voice of the patient is heard is reflected in the recent appointment of  a member of the AHSN Lay Partner organisation.

Our purpose

To ensure that maternity and neonatal services in the Thames Valley region are investigating and learning from incidents and that the learning is shared within the Local Maternity Systems (LMS) as identified in A Five Year Forward View for Maternity Services and in Each Baby Counts Report (RCOG, 2017).

Our objectives

  • To agree a strategy for the investigation of clinical incidents to reduce variation in practice and to develop a forum to share the learning within the Local Maternity Systems.
  • To engage with partners and stakeholders to develop a multidisciplinary approach to learning from incidents and share the learning to prevent harm associated with preventable incidents in maternity care.
  • To engage with partners and stakeholders to explore new opportunities/ initiatives relevant to the group and promote innovation and learning from excellence in practice.
  • To support, collaborate and learn from each other
  • To support each other in the implementation of national tools for example the Perinatal Mortality Review Tool (PMRT)
  • To ensure cognisance with developments in the national agenda for example the role of the Healthcare Safety Investigation Branch (HSIB)

Quote from Miss Jill Ablett, Consultant Obstetrician, Royal Berkshire Hospital – member of the Regional Perinatal Governance Group

‘I have really valued being involved in the setting up and ongoing development of this regional perinatal governance group which has added externality and validation to our own unit’s governance policies.  These independent views and discussions are helpful both for sharing learning but also for delivering assurance to our Trust Boards and Executives about our individual services.

This unique group of Obstetricians, Neonatologists, Midwives and Risk Managers from across the wider region has shared incidents in an open and honest way in order to promote learning and development in the wider community and extend the patient safety agenda.

The case I have quoted the most as an example of sharing was that of the neonatal hypoglycaemia from RBH.  The investigation was done with external input from Bucks and produced actions and learning for both units.  When presented at the forum, I recall that all the other units declared similar events and thus the learning and external review could be shared rapidly and effectively with other units to aid their governance processes.’

 

Collaboration with national organisations

Perinatal Mortality Review Tool

The group receive expert input from relevant specialist organisations, e,g Professor Jenny Kurinczuk, National Programme Lead for MBRRACE UK who led a discussion on the implementation of the Perinatal Mortality Review Tool (PMRT).  The PMRT is a standardised nationally accepted tool, web-based and includes a system for grading quality of care linked to outcomes.

Health Safety Investigation Branch (HSIB)

A Maternity Investigations Team Leader presented the background, roll out and investigation process to raise awareness of the HSIB maternity investigation programme to the group in October 2018.  The group benefits from HSIB sharing learning from investigations and HSIB have agreed to share themes of findings and recommendations in the future.

Collaboration with the Patient Safety Academy (PSA) and Incident Investigation training.

In January and March 2019, the PSA, in collaboration with the Oxford Patient Safety Collaborative, delivered a 2-day bespoke incident analysis investigation training programme to the Regional Perinatal Clinical Governance Group.

The programme is free to organisations and is funded by Health Education England. The methodology is based on training staff involved in incident investigations in the principles underpinning a Human Factors approach and system analysis methods.

Reporting and assurance

The group report into the safety workstream for the Buckinghamshire, Oxfordshire and Berkshire West Local Maternity System (BOB LMS) and each organisational representative report individually to their own organisations to ensure that communication is robust.

For further information please email eileen.dudley@oxfordahsn.org