Nottingham hospital bosses are unlikely to meet a deadline to clear a backlog of incomplete investigations into serious maternity incidents. Nottingham University Hospitals Trust (NUH), which runs the Queen’s Medical Centre and City Hospital, currently has 53 outstanding maternity incidents which have not yet been investigated.
Serious incidents are unexpected or unintended events that could cause NHS patients harm. The trust had said in September it had a ‘backlog’ of incidents which were due to be investigated. In an update, the trust said it has managed to clear a number of those incidents – but it declared another nine in September and October 2022.
NUH had previously said it had a target completion date for investigations by December 23 – but in the November board meeting, the director of midwifery admitted they had not progressed as quickly as she would have hoped. Maternity services at the trust have been declared ‘inadequate’ by health watchdogs.
Read more: 61 serious incidents at Nottingham maternity units still being investigated
Director of Midwifery Sharon Wallis said during the meeting: “Our burning platform at the minute is our serious incidents. As you are aware we have identified a backlog in our serious incident investigations and action plans. It has been an absolute focus for us.
“We have 53 Serious Incidents, nine have been identified since September/October which leaves us with 44 in the backlog. In reality, we will probably get to 19 or 20 by the end of December.
“I am taking personal responsibility on this and we are absolutely driving that forward. It’s not where we wanted to be or predicted to be.”
She added that 35 investigations had been closed off since April 2022 which she said was an “astounding number”. NUH has lowered the threshold for what is classed as a Serious Incident, which has increased the number which are declared.
Ms Wallis said: “We may be an outlier for numbers but it is the right thing to do to reflect the experience of women and families in our Serious Incidents. We are passionate that we need to reflect that experience, regardless of whether we caused that injury or insult to the individual.”
Non-executive director at NUH Professor John Atherton said: “The quality and assurance committee was a bit disappointed that the Serious Incidents hadn’t been delivered by December, we understand many of the reasons behind that. We think it’s very important we focus on quality and learning from SIs.
“We had assurance that Serious Incidents are being dealt with well. The issue really is in clearing that backlog in a timely way. We have asked the team to go away and come back with a very detailed plan on how they are going to clear that backlog with timeframes.”
Ms Wallis added that the trust is seeing a “significant reduction” in incidents that are reportable to the Healthcare Safety Investigation Branch (HSIB) – which investigated maternal deaths, neonatal deaths, stillbirths, or severe brain injury in babies. She said the trust was seeing nine or 10 of these a year ago and currently has four incidents with HSIB.
She said: “That’s a positive in terms of safe care and practice.” Chief Executive Anthony May added that NUH is on a “very steep improvement curve and that brings with it risks and issues”.
He said: “It’s a difficult challenging journey and we see the work of Donna Ockenden and we see that as a really important part of the trust’s development. We must continue to give it every effort and all our resources in an open and transparent way. We are providing Donna with what she needs to get on with her review.
“On Monday a letter will go to 1,000 families from me encouraging them to engage with the review and offering an opportunity to meet with me. We don’t want to wait till the end of Donna’s review to learn any lessons.”
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