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Review of 18 UHMBT recommendations from The Kirkup Report (2015) published

29 June 2021

The Trust recently carried out a piece of work that was focused on whether the improvements made in maternity services as a result of the findings of the Kirkup Report have been sustained.

The report from this piece of work will be considered by the Trust Board at the public Board meeting tomorrow (Wednesday 30 June). 

It is important to note that this was not intended to be a service review but a defined piece of work commissioned by the Trust Board focused on whether the implementation of the 18 Trust Kirkup recommendations had been sustained to this day. The Care Quality Commission - which regulates all health and social care services - recently carried out an inspection of some of our services, including maternity. We are still awaiting the final findings from this inspection, which may include recommendations for further improvements. 

As a Trust, in April 2016, we published our ‘One year on - how we implemented the Kirkup recommendations’ report that detailed how our teams had worked together to implement the 18 recommendations for our Trust.

We always intended to do a review five years after the publication of the Kirkup report to allow us to see how we were progressing with the recommendations for maternity services - not only in implementing the recommendations but whether we had embedded them into our day-to-day practice. Unfortunately, due to the COVID-19 pandemic and pressures on clinical teams, this was delayed but was approved by the Trust Board in November 2020.

The panel that carried out the piece of work was made up of seven individuals with expertise and experience in areas such as engagement with service users, maternity, nursing, safeguarding, and anaesthetics. This breath of experience was to ensure that they could represent the voices of service users, colleagues, academics and regulators.

The panel were asked to assess each recommendation to decide whether:

  • The recommendations that were implemented following the publication of the report in 2015 were still fully embedded in practice
  • The recommendations had been superseded by more up to date evidence based practice and if this was the case, was the evidence there to support this being embedded at the Trust.

The panel reviewed an extensive amount of evidence supported through interviews and focus groups with various individuals and teams, including service users, colleagues, regulators, and stakeholders; as well as looking at data, documents and information.

After reviewing all of the evidence, the panel concluded that the Trust had ‘fully sustained’ 15 of the 18 recommendations, with the three remaining recommendations being ‘partly met’. The three ‘partly met recommendations were:

  • Recommendations 6 and 7 regarding risk assessments which the panel would consider to be fully met with the implementation of the dedicated electronic patient record for maternity - due to launch across NHS trusts in Lancashire and South Cumbria this year, and in Morecambe Bay in summer.
  • Recommendation 12 regarding the structures and processes of incidents and the involvement of colleagues. The panel would consider this fully met once more recent action plans are complete and subsequent audits over a year show further evidence of sustained improvement - due to be complete by June 2022

In addition, the Trust asked the panel to consider and make a judgement against three additional questions around how the Trust handles adverse incidents within maternity services, whether there is evidence of continued improvements within these services; and how culture and behaviours in maternity services were progressing. For each of the three additional areas, the panel acknowledged significant progress, with some actions identified to improve further recommended.

The report which includes more details on the panel and the process can be found here

It was presented to our Quality Assurance Committee in May 2021 and will go to the public Trust Board meeting on 30 June 2021.

Whilst we take assurance from the improvements found, it has also highlighted areas where we can do further work. Some of the timings are out of our control, such as the system wide launch of the new maternity electronic patient record, but for those that we can control, we will be putting extra focus on the areas to ensure we deliver the changes quickly.

We strongly hold our commitment to those who tragically lost loved ones, our colleagues, those that use our services, and our local communities that we would ensure improvement and learning are embedded in our service. Our teams in maternity and the supporting services are committed to making services the best they can be for women and families; and as a Trust, we will support them to do what needs to be done.

On behalf of the Trust, we’d like to extend our thanks to the panel for their dedication to what has been a challenging piece of work for them. We’d also like to thank our teams which have supported this piece of work during what remains an extremely busy time for NHS services.