Thank you, Deputy Presiding Officer, for giving me the opportunity to make this statement.
Members will be aware that in December 2016, I asked Healthcare Improvement Scotland (HIS) to undertake an independent review of the management of adverse events within Ayrshire Maternity Unit at University Hospital Crosshouse, and that this was commissioned in response to concerns raised by families about the management of adverse events in the unit.
Let me begin by extending my heartfelt condolences and sympathy to the families involved with this review, sentiments that I am sure everyone in this chamber shares. NHS Ayrshire and Arran have already apologised and I want to extend my personal and sincere apologies to the families affected.
I would also take this opportunity to thank the many members here today who have made representations on behalf of constituents and who took a keen interest in the review and its outcome.
This review followed two previous relevant reviews into management of adverse events in NHS Ayrshire and Arran carried out by HIS in 2012 [The management of significant adverse events in NHS Ayrshire & Arran report 2012] and 2013 [NHS Ayrshire and Arran management of adverse events review report 2013].
To ensure we heard from all the families who wanted to share their stories, I sought assurance from HIS that no families would be excluded and that their views and experiences would be reflected in the final report.
Sixteen families in total were involved in contributing to the HIS review, and HIS have shared the findings of the review with the seven families who wanted feedback, which has delayed the publication slightly.
The report makes eight recommendations for improvement, six for NHS Ayrshire and Arran focused on:
- changes to the adverse event review process to ensure it meets the National Framework and provides simple, useful and practical processes
- improved family engagement and communication to ensure families are provided with the right information, support and opportunities to be involved in a significant adverse event process
- improved support for staff, including dedicated time to be involved in all aspects of adverse event reviews, including protected training time
- promotion of shared learning internally and externally from their improvement work, including publication of learning summaries of adverse event reviews
- revised procedures for publication of reports so they preserve patient and family confidentiality and at the same time encourage shared learning
- improved identification of and access to training for staff, including producing a training needs analysis and ensuring access to training programmes
One recommendation is directed to HIS to ensure the findings of this review support the further development of the National Framework for Adverse Events and the Quality of Care Review approach. One recommendation is for NHSScotland to develop and agree a list of mandatory skills and competencies for maternity services.
In parallel with the HIS review, NHS Ayrshire and Arran commissioned an independent team of experts from the University of Leicester to review the clinical care in recent cases of stillbirth and neonatal death in the maternity unit [External Clinical Review of Perinatal Deaths from NHS Ayrshire & Arran, 2017].
The team examined several cases and concluded that it is possible that differences in care may have led to different outcomes for some of these babies. The report recommendations focus on quality of care, staffing and improvement activity in the unit.
I also want to highlight to Parliament two other reports that were published last week that look at stillbirth and neonatal death. On 21 June the Royal College of Obstetricians and Gynaecologists published a report into the findings of their Each Baby Counts programme. The report made expert recommendations for improvements to the quality of care for mothers and babies to reduce stillbirth and early neonatal death.
On 22 June, Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE) published their Perinatal Surveillance report, which provides an indication of the relative rates of stillbirth and neonatal death across the UK in 2015, and shows Scotland has the lowest stillbirth and neonatal death rates anywhere in the UK.
These reports are important because they highlight incidence across Scotland, but also because they show where general improvements can be made to services, and that fewer families are experiencing this loss every year, and we should welcome that.
Action in light of reports
Turning back to the HIS and University of Leicester reviews.
I have spoken today to the Vice Chair of NHS Ayrshire and Arran and I have made it very clear to the Board that I view the substandard practices uncovered in these reports as unacceptable.
NHS Ayrshire and Arran has apologised to families and offered to meet and discuss their cases with them in person. The Board has contacted families directly, or are working with the stillbirth charity Sands to contact other families. Sands will also offer their full bereavement support to any of the families who want it.
The Board has also today published a set of Action Plans to implement the recommendations. This includes plans to appoint a Risk and Quality Improvement Team for maternity services, comprising senior maternity staff to support the changes required in the Action Plans.
The Board has also invested £1 million in midwifery staffing since 2014, and in addition has appointed an additional consultant obstetrician and clinical risk midwife.
I welcome this response from NHS Ayrshire and Arran, and have been clear with the Vice Chair that I expect these plans to be implemented and evidence of the improvements published. I will meet with the Board soon to get an update on implementation, and am happy to report back to Parliament on progress.
HIS will monitor progress against the implementation of the recommendations every three months in the first instance. This information will be fed into the wider Quality of Care Review assessment for this Board. Quality of Care Reviews of NHS Boards will commence in the autumn, and these will include a focus on the leadership and governance issues surfaced by this HIS review. The whole-Scotland issues will also be fed into performance reviews with NHS Boards across the country.
We will work in partnership with Health Boards to agree a core mandatory update training programme for maternity staff before the end of the year.
It is very important that we reassure people, particularly expectant mothers, about the overall safety of our maternity services.
Our rates of stillbirth and neonatal death continue to decline and, according to the MBRRACE report, in 2015 we had a record low rate for Scotland, and approaching the rates of the best performing Scandinavian countries. NHS Ayrshire and Arran has seen a 50% reduction in its stillbirth rate over the last three years as a result of improvement activity already undertaken.
In light of the Kirkup report into services in Morecambe Bay, we instigated our Review of Maternity and Neonatal Services in Scotland. The Best Start report was published earlier this year; implementation of the 76 recommendations is underway, and will deliver safer and higher quality maternity care for women and babies.
Other activity underway
I want to also highlight a range of other activity focused on learning from adverse events and continuous improvement, including:
- the Scottish Patient Safety Programme, in particular the Maternity and Children Quality Improvement Collaborative (MCQIC) programme, which aims to improve safety in maternity, neonatal and paediatric services
- greater consistency and improved quality of adverse event investigation and reporting through the Adverse Events Framework
- the Duty of Candour provisions, which will come into effect on 1 April 2018; The Apologies Scotland Act 2016; a revised NHS Complaints Procedure; and the ability for individuals to raise concerns independently through Care Opinion
In addition I have asked my officials to prioritise a programme of work to support more effective learning systems within NHS services that support people affected by adverse events, conduct rigorous reviews and share findings. This work will be overseen by the Chief Medical Officer (CMO) and the National Clinical Director.
I have also written to all Health Boards drawing attention to the findings, and asking those Boards with above average rates of stillbirth and neonatal death to undertake independent reviews of the quality of care and then report back on plans for improvement.
Later this year our Standardised Perinatal Mortality Review Tool will be launched, which will ensure all cases of stillbirth and neonatal death are systematically investigated, and that parents and families are fully engaged in that process to ensure they get the answers they need as quickly as possible.
Finally I want to return to the people who matter most: that is the families who have been part of this review and have bravely shared their experiences with HIS, with me and with some of my colleagues here in the chamber. It was thanks to them that this investigation took place and the resulting improvements to care have happened and will happen. And I want them to thank them for the dignity and determination they have shown.
I have offered to meet all of those families whose cases were included in the report to discuss the findings and listen further to their views. These meetings will be arranged over the next few weeks.
However in recognition of the role they have played in raising awareness I would also like to offer them the opportunity to be involved in the oversight of improvements. I will establish an Oversight Group, comprising families and representative organisations, to take forward scrutiny from the service users' perspective of changes that are happening not only in Ayrshire and Arran, but in maternity and neonatal services across Scotland.
I have written to all Boards making it clear that I expect them to be open and proactive in their communications with families who want to discuss any concerns about their care, and I would encourage any family who may have unanswered questions related to their maternity care to contact their local Board.
I give my personal commitment to the Ayrshire families that action will be taken in light of these findings. I have already expressed my sympathies and apologised to the families, but I also want to record my thanks to them, and I am hoping to do this in person when I meet with them and I am sure that the chamber will want to join with me in expressing our gratitude.
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