Meeting of the Parliament

Meeting date: Tuesday, June 27, 2017

Official Report 978KB pdf

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NHS Ayrshire and Arran Maternity Services (Review of Management of Adverse Events)

The next item of business is a statement by Shona Robison on NHS Ayrshire and Arran maternity services: Healthcare Improvement Scotland’s review of adverse events. The cabinet secretary will take questions at the end of her statement, so there should be no interventions or interruptions during it.

15:12  

Thank you, Presiding Officer, for giving me the opportunity to make this statement.

Members will be aware that, in December 2016, I asked Healthcare Improvement Scotland to undertake an independent review of the management of adverse events in the Ayrshire maternity unit at University hospital Crosshouse in response to concerns that had been raised by families about the management of adverse events in the unit.

I extend my heartfelt condolences and sympathy to the families that were involved with the review—sentiments that, I am sure, everyone in the chamber shares. NHS Ayrshire and Arran has apologised, and I extend my personal and sincere apologies to the families that are affected. I also take this opportunity to thank the many members here who have made representations on behalf of constituents and who took a keen interest in the review and its outcome.

The review followed two previous relevant reviews into the management of adverse events in NHS Ayrshire and Arran that were carried out by HIS in 2012 and 2013.

To ensure that 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. In total, 16 families contributed to the HIS review, and HIS has shared the findings of the review with the seven families who wanted feedback, which has delayed the report’s publication slightly.

The report makes eight recommendations for improvement. Six of those are for NHS Ayrshire and Arran, and they focus on changes to the adverse event review process to ensure that it meets the national framework and provides simple, useful and practical processes; improved family engagement and communication to ensure that 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; internal and external promotion of shared learning from improvement work, including the publication of learning summaries of adverse event reviews; revised procedures for the publication of reports so that they preserve patient and family confidentiality and, at the same time, encourage shared learning; and improved identification of and access to training for staff, including the production of a training needs analysis and the ensuring of access to training programmes.

One recommendation directs HIS to ensure that the findings of the review support the further development of the national framework for adverse events and the quality of care review approach. The other recommendation is that NHS Scotland develops and agrees 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. The team examined several cases and concluded that it is possible that differences in care may have led to different outcomes for some of those babies. The recommendations in the report focus on the quality of care, staffing and improvement activity in the unit.

Two other reports that were published last week look at stillbirth and neonatal death. On 21 June, the Royal College of Obstetricians and Gynaecologists published a report into the findings of its each baby counts programme. The report made expert recommendations for improvements to the quality of care for mothers and babies to reduce the incidence of stillbirth and early neonatal death. On 22 June, MBRRACE—mothers and babies: reducing risk through audits and confidential enquiries—published its perinatal surveillance report, which provides an indication of the relative rates of stillbirth and neonatal death across the United Kingdom in 2015. It shows that Scotland has the lowest stillbirth and neonatal death rates anywhere in the UK. Those reports are important because they not only highlight incidence across Scotland but show where general improvements can be made to services. We should welcome the fact that fewer families every year are experiencing the loss of a baby.

I return to the reviews by HIS and the University of Leicester. I have spoken today to the vice-chair of NHS Ayrshire and Arran and have made it clear to the board that I view the substandard practices that were uncovered in those reports to be unacceptable. NHS Ayrshire and Arran has apologised to the families and has offered to meet them in person to discuss their cases. The board has contacted families directly and is working with the stillbirth charity Sands to contact other families. Sands will also offer its full bereavement support to any families who want it.

The board has today published a set of action plans to implement the recommendations and aims to appoint a risk and quality improvement team for maternity services, comprised of senior maternity staff, to support the changes that are required by the action plans. The board has invested £1 million in midwifery staffing since 2014 and has appointed an additional consultant obstetrician and clinical risk midwife. I welcome that response from NHS Ayrshire and Arran and have been clear with the vice-chair that I expect those plans to be implemented and evidence of the improvements to be published. I will meet the board soon to get an update on implementation, and I will be happy to report back to the Parliament on progress.

HIS will monitor progress against the implementation of the recommendations every three months in the first instance, and that information will be fed into the wider quality of care review assessment for the board. Quality of care reviews of NHS boards will commence in the autumn and will include a focus on the leadership and governance issues that have surfaced in the 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 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. According to the MBRRACE report, in 2015 we had a record low rate for Scotland, and we are approaching the rates of the best-performing Scandinavian countries. NHS Ayrshire and Arran has seen a 50 per cent reduction in its stillbirth rate over the past three years as a result of the improvement activity that has been undertaken.

In the light of the Kirkup report into services in Morecambe Bay, we instigated our review of maternity and neonatal services in Scotland, and the report “The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland” was published earlier this year. Implementation of its 76 recommendations is under way and will deliver safer and higher-quality maternity care for women and babies.

A range of other activity is focused on learning from adverse events and continuous improvement. The Scottish patient safety programme—in particular, the maternity and children quality improvement collaborative—aims to improve safety in maternity, neonatal and paediatric services. There is greater consistency and improved quality of adverse event investigation and reporting through the adverse events framework. The duty of candour provisions will come into effect on 1 April 2018. The Apologies (Scotland) Act 2016 is now in force. We have a revised NHS complaints procedure, and individuals are able to raise concerns independently through care opinion.

In addition, I have asked my officials to prioritise a programme of work that supports more effective learning systems in NHS services that support people who are affected by adverse events, to conduct rigorous reviews and to share findings. That work will be overseen by the chief medical officer and the national clinical director.

I have also written to all health boards, drawing their 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 to report back on their plans for improvement.

Later this year, we will launch our standardised perinatal mortality review tool, which will ensure that all cases of stillbirth and neonatal death are systematically investigated and that parents and families are fully engaged in the process so that they get the answers that they need as quickly as possible.

In concluding, I return to the people who matter most: the families who have been part of the review and have bravely shared their experiences with HIS, with me and with some of my colleagues in the chamber. It was thanks to them that the investigation took place and that the resulting improvements to care have happened and will happen. I thank them for the dignity and determination that they have shown. I have offered to meet all those families whose cases were included in the report to discuss the findings and to listen further to their views. Those meetings will be arranged over the next few weeks.

However, in recognition of the role that those families have played in raising awareness, I also offer them the opportunity to be involved in the oversight of improvements. I will establish an oversight group comprising families and representative organisations to undertake scrutiny from the service users’ perspective of the changes that are happening not only in NHS Ayrshire and Arran but in maternity and neonatal services throughout Scotland.

I have written to all NHS 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 encourage any family who have unanswered questions relating to their maternity care to contact their local board.

I give my personal commitment to the Ayrshire families that action will be taken in the light of the review’s findings. I have expressed my sympathies and apologised to the families, but I also record my thanks to them, as I hope to do in person when I meet them. I am sure that the chamber will want to join me in expressing our gratitude.

I am happy to take questions.

Thank you. The cabinet secretary will now take questions on the issues that were raised in her statement. I intend to allow around 20 minutes for questions, after which we will move to the next item of business.

I thank the cabinet secretary for early sight of her statement. I also declare an interest in that my daughter is a healthcare professional in the NHS.

Apart from the fact that HIS has had its wings well and truly clipped by the very narrow instruction from the cabinet secretary on what it was permitted to investigate, the report throws up some glaring issues. Red flags that should have been noted have been flying for the best part of a decade. From 2009 to 2012 there were 57 adverse event reviews in NHS Ayrshire and Arran. Following an HIS review that was instigated by the then health secretary, Nicola Sturgeon, the number of such reviews fell to zero in 2013, only one in 2014 and seven in 2015. That is a significant key indicator that should have thrown up a massive red flag and at least been investigated.

When I asked HIS directly about the implications of those numbers, it answered that it does not routinely monitor those figures. The HIS report states:

“The NHS Ayrshire and Arran significant event review process was not used for significant events in the maternity unit”.

Given that HIS has categorically stated that it is not its responsibility, I ask the cabinet secretary who is responsible for monitoring the implementation of recommendations from the HIS review, how that will be measured and how the families affected by these tragedies, as well as NHS staff, can have any faith that this review, which is subsequent to the 2012 and 2013 reviews, will change anything?

I thank Brian Whittle for his questions and his long-term interest in this issue. It has been important that members have raised issues on behalf of constituents. Doing so has helped to ensure that those reviews have shed a light on many aspects of practices in NHS Ayrshire and Arran that have not been acceptable.

I think that Brian Whittle acknowledged that the HIS report is very thorough. It goes beyond the significant adverse event review process, although it deals with that in some detail, and gets into very important issues such as communication with the families and the way in which boards should engage with families when something goes wrong.

On what happens going forward, I give the member an assurance that, as I laid out in my statement, HIS will monitor NHS Ayrshire and Arran’s implementation of the recommendations on a three-monthly basis. I will take a close personal interest in the matter and will meet the board to get a personal reassurance on the implementation. The board has established mechanisms to ensure that oversight is provided at the most senior level. We should recognise that NHS Ayrshire and Arran has already taken many steps to improve the services. The external verification of the quality of services in Ayrshire and Arran shows a very different picture from before.

I hope that Brian Whittle takes some comfort from that. I am happy to keep him and other members closely informed on progress as we take forward that work.

I join the cabinet secretary in sending heartfelt condolences to all the individuals and families who have been affected by these tragedies.

Although the report covers NHS Ayrshire and Arran, there is clearly a wider issue, with adverse events having taken place in other maternity units in Scotland. It is believed that there are between two and three preventable deaths of babies in Scotland each week. Therefore, although I welcome the recommendations on how to deal with adverse events, it is unfortunate that the report did not investigate the quality of care or give recommendations on how to prevent adverse events. The HIS report, a recent Bliss Scotland report and the maternity and neonatal services review all point towards a workforce crisis, with understaffed wards, high vacancy rates and high use of agency staff, which are having an impact on patient care and safety.

The recommendations of the maternity and neonatal services review are now being implemented, but when will the reduction in neonatal intensive care units commence and when will it be completed? Given that families are at the heart of the situation, has the cabinet secretary considered having an independent public inquiry that would give confidence to the families? When will the cabinet secretary come back to Parliament to give us an update on how the HIS review is being implemented and which recommendations have been taken forward?

On that last point, I will be happy to give regular updates to Parliament on the local implementation in Ayrshire and Arran and the wider changes that are being made.

Anas Sarwar makes an important point about the prevention of adverse events. The reviews are very important and the actions that they set out and the implementation of the changes will ensure that our services are as safe as they can be. As we know, events happen in our NHS that are difficult to predict and are sometimes unavoidable. However, we are talking about trying to prevent avoidable adverse events.

One of the key elements in the recommendations is on mandatory cardiotocography—CTG—training, which relates to foetal heart rate monitoring. The chief medical officer will ensure through medical directors that that happens. That is important. Mr Morton raised the issue very directly as a key weakness in the sad case of the death of his son, Lucas. I say to Mr Morton that I hope that the recommendation gives him personal reassurance on that important issue of the training of midwives in interpreting CTG. It will be mandatory for midwives to attend a minimum of two sessions per annum, and the CMO will have oversight of that.

We have had a number of inquiries and reviews. The HIS review and the Leicester review have identified a number of issues that now have to be resolved. Many of those important changes and improvements have already been made, and these recommendations lay out what more has to done. The most important thing is that we get on and do that. The actions that have already been taken and those that will be taken will give us the best chance of avoiding future unnecessary and avoidable deaths in our units.

I have 10 members wishing to ask questions. I ask you to be disciplined and go straight to your questions to allow all members in on this very important and sensitive issue.

Having just received the report and spoken to the chief medical officer, I think that it is clear that NHS Ayrshire and Arran did not fully implement the recommendations that were made to it in 2012 and 2013 with respect to training for staff and openness and transparency in how it supported affected families. What action does the cabinet secretary propose to take on this review to improve safety and to ensure and verify that any new recommendations are carried out? How can NHS Ayrshire and Arran regain the trust of all the families affected by these tragic events?

I recognise that Willie Coffey has also raised cases with me directly. I am glad that he met the chief medical officer, as, I think, did Brian Whittle. The chief medical officer went through some of the detail on what is a set of very complex issues and complex reports that go into quite some detail.

The question that Willie Coffey asked is a simple one: how can we be assured that these recommendations—which, if implemented, will make a difference and, importantly, make our services safer—will be implemented? First, I will make sure that, through the oversight that the Scottish Government provides through the chief medical officer and our clinical director, we keep a very close eye on the implementation of the recommendations not just by NHS Ayrshire and Arran but by the rest of our health boards. As I said in my statement, I have written to the boards setting out my expectations on that.

There will be mandatory training. That will be monitored to make sure that midwives are getting the opportunity to have that critical training. We also expect HIS to get a very close three-monthly update on how the recommendations are being implemented, as it is doing with NHS Ayrshire and Arran. I hope that all of that taken together will give Willie Coffey—and, importantly, the families—reassurance that the recommendations will be taken forward. It is important to recognise the improvements that have already been made in Ayrshire and Arran, including the 50 per cent reduction in the rate of stillbirths since 2013. That should be acknowledged.

There was an HIS review in 2012 and another in 2013. Today we are looking at the recommendations of another review in 2017, with an unfortunate sense of déjà vu on some of the points that it makes. As Brian Whittle pointed out, HIS is not a regulatory body and it does not have the power to instruct health boards to comply with its conclusions. What measures are available to the cabinet secretary, in addition to the measures that she laid out in her answer to the previous question, if health boards do not comply with the recommendations of the various reports?

Ultimately, I have ministerial powers of direction over health boards. However, I hope that the measures that I have set out will be taken forward by health boards of their own accord. At the end of the day the health boards should be, and I am sure will be, motivated to want to provide the best possible and safest services to babies and their mums.

It is important to note that when HIS undertakes an independent review, it brings in people from outside. For example, the recent review was chaired by Dr Tracey Johnston, who is a consultant obstetrician at Birmingham women’s hospital and brought that external independent view of the service. It is fair to say that that has shone a light on areas of practice that need to improve.

I also point out that HIS has the same independent legal status as the Care Quality Commission in England. Ministers appoint to each body in the same way north and south of the border. HIS also has powers of intervention that can, for example, close wards. HIS has extensive powers, as do I. I hope that boards will get on with implementing the changes that have been recommended, and there will be strong and close oversight to ensure that that happens.

The halving of stillbirths and neonatal deaths in NHS Ayrshire and Arran over three years is very welcome progress. Nevertheless, does the cabinet secretary accept that many bereaved parents in Ayrshire feel that some of their questions remain unanswered or have been answered only after intensive lobbying by MSPs, patient groups and others on their behalf?

Will all the recommendations be implemented by other health boards? What further steps will be taken to minimise the number of stillbirths and neonatal deaths not just in NHS Ayrshire and Arran, but across Scotland?

I recognise how much of an interest Kenny Gibson has taken and continues to take in these issues. He makes some extremely important points about the bereaved families and their questions, some of which they might feel remain unanswered. I will meet the families who want to meet me. We will talk about whether they feel that there remain unanswered questions, and we will look at how we can ensure that they get answers to any such questions.

We expect all health boards to implement the recommendations. For understandable reasons, the focus has, of course, been on NHS Ayrshire and Arran, but we expect all health boards to implement the recommendations.

As far as external assurance is concerned, as Kenny Gibson will, I hope, be aware, MBRRACE-UK was established as a UK surveillance team to shine a light every year on those units that are above the average for stillbirths and neonatal deaths. That work is very important. Through it, we can see that Scotland’s units performed very well indeed in 2015. Scotland had the lowest rates of stillbirths and neonatal deaths across the UK, but we are absolutely not complacent. There is more work to be done to ensure that that improvement continues, and I am determined to make sure that that happens.

The review praises maternity staff at Crosshouse hospital for their professionalism but highlights the impact of staff shortages. It reveals that, in March 2017, a senior manager in NHS Ayrshire and Arran said that staff shortages were

“contributing to our ability to deal effectively with day to day workload and provide effective and safe care for women, children and neonate.”

They went on to say that that meant that staff could not be released for training and that, as a result,

“staff will not be trained to the standard to provide assurance of the quality of care being delivered.”

Although NHS Ayrshire and Arran has now increased the level of staffing, can the cabinet secretary give a personal assurance to families across Scotland that all our maternity units are adequately staffed and that those staff have the training that they need?

It is absolutely critical that all units apply the workload planning tool. As part of our work going forward, we will want to make sure that all units are doing that.

The member rightly pointed to the staffing increase in the Ayrshire maternity unit. That increase has been significant—between 2014-15 and 2016-17, the number of whole-time equivalents rose from 181.34 to 196.77. Since April 2016, additional funding for 6.6 whole-time equivalent midwives has been agreed, and at the end of June 2017 an additional 14 whole-time equivalent midwives are in the process of being recruited. That is because of the application of the midwifery workload planning tool. We expect that tool to be applied to all units to make sure not only that each unit has the right number of staff, but that the staff resource reflects the needs of the patient cohort and can be adjusted depending on the needs of the patients in the unit.

I remind members that I have a licence to practise as a registered nurse.

What financial support will be provided to help NHS Ayrshire and Arran implement the recommendations that are outlined in the report?

We should recognise that NHS Ayrshire and Arran has invested more than £1 million in additional staffing, particularly in expanding its midwifery workforce.

In terms of additional resources, we are ensuring that we support NHS Ayrshire and Arran with Scottish Government people and expertise. Healthcare Improvement Scotland will be doing likewise, and NHS Ayrshire and Arran has established an oversight team, which it has resourced to ensure that it can have confidence that the recommendations are taken forward. We will continue to speak to Ayrshire and Arran about any other support that it may require.

I am glad that the cabinet secretary has highlighted the valuable role that Sands plays. I would appreciate it if she could tell us how the Scottish Government is drawing on Sands’s expertise to improve support for bereaved parents. There has been some discussion of a national bereavement strategy. Can the cabinet secretary offer any updates on that strategy and how it might reflect the psychological and emotional support that parents need in these most devastating circumstances?

I thank Alison Johnstone for her question and I thank Sands for the support that it has provided, and has offered to provide, to families, and which it will continue to provide in any further meetings that families want to undertake with the board, with me or with others. Sands provides a very important service. Work is on-going on the national bereavement strategy, and I would be happy to write to Alison Johnstone to update her on that. It is important that families that want that support—not all will—are offered it as quickly as possible.

Does the cabinet secretary recognise that the emotional support referred to by Alison Johnstone, which is available to families affected by stillbirth, is not universally available across Scotland? What additional support will her Government extend to charities such as Sands, and what will she do to extend NHS support to those families who are dealing with the long-term emotional trauma of adverse events and who live in health board areas not currently served by specialist perinatal mental health teams?

We expect boards to ensure that families get the support that they require no matter where they live in Scotland. Sands is a key organisation providing that support and we will have an on-going dialogue with it about how we can ensure that it is supported in order to continue doing that work. We will ensure that, when families come forward, boards listen to what they have to say and that there is an open culture of hearing and listening and of acting on concerns raised by families. Changes will be made by legislation to require boards to have a more open and transparent culture in terms of the duty of candour, and that will help to create a culture in which people can come forward and that, when they do, they will get the support that they need.

I apologise to Clare Haughey, Donald Cameron and Fulton MacGregor, who were not called, but I thought it best on this topic to allow longer questions and longer answers. That concludes questions to the cabinet secretary.