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It is essential that the questions raised by families affected by failings in maternity care at Nottingham hospitals are addressed. However, it is equally important that families who are currently accessing maternity services can be reassured that steps are being taken now to ensure that the current service is safe and effective, pending what may be found by Ockenden’s review. Common themes have emerged from recent reviews of maternity and neonatal services [refs], and as recently noted [1] these themes are not new but to address them requires appropriate resourcing of maternity services in the widest sense in addition to changing longstanding cultural issues.
Adverse perinatal outcomes can occur without warning and despite good care. Incident and case review should be part of routine clinical governance procedures, but are often of poor quality and do not engage the appropriate professionals within the multidisciplinary team [2]. Learning is therefore either not identified or subsequently not embedded into practice. It is in this arena that external peer review would be beneficial.
External peer review was recommended in the Perinatal Mortality Review Tool’s first report [3] to ‘provide a ‘fresh pair of eyes’ to the review of the care provided and to provide robust challenge where complacency or ‘group think’ in service provision, as identified in the Kirkup report, has crept in.’ This has further been reinforced by the recently published Ockenden report ‘External clinical specialist opinion from outside the Trust (but from within the region), must be mandated for cases of intrapartum fetal death, maternal death, neonatal brain injury and neonatal death’ and ‘[critical] oversight [of patient safety] must be strengthened by increasing partnerships across Trusts within local networks of neighbouring Trusts.’ [4]
We believe that external peer review should be from outside of the local network, particularly when seeking to review complex neonatal or obstetric care that may only be delivered in one centre in any particular network. Over the last 4 years we have undertaken reciprocal peer mortality review of neonatal cases in the Royal Victoria Infirmary, Newcastle upon Tyne and the Royal Jubilee Maternity Hospital, Belfast. In-person attendance at case reviews has moved on-line since the Covid pandemic and we have had to address the challenges of sharing patient notes in a virtual environment.
We have learnt that:
• External opinion is a powerful tool for influencing change, for example raising awareness of staff shortages or building the case for more allocated Consultant time for service provision.
• External review can, where appropriate, reassure that practice is acceptable.
• External review can help improve the overall review process, for example by suggesting input from other specialists.
• The volume and depth of learning from those cases with external review appears to be higher compared to those without. This may be due to case selection or to the richer discussion that comes from a more diverse group. We have identified learning that would not have otherwise occurred. Importantly there has been reassurance that the local teams are not providing care or performing reviews that are influenced by ‘group think’.
• Even when external (to network) reviewers are not present, case review processes have become more robust and generate richer discussion and outputs.
• This process could be readily adapted for use in many other healthcare settings.
For external peer review to be of benefit requires appropriate resource allocation, from administrative support to ensure notes are available, to adequate IT facilities and recognition of the formal time commitment required to undertake this critical activity for all members of staff. Failure to implement this process would lose a major opportunity to improve the quality of care.
Re: Ockenden: another shocking review of maternity services
Dear Editor
It is essential that the questions raised by families affected by failings in maternity care at Nottingham hospitals are addressed. However, it is equally important that families who are currently accessing maternity services can be reassured that steps are being taken now to ensure that the current service is safe and effective, pending what may be found by Ockenden’s review. Common themes have emerged from recent reviews of maternity and neonatal services [refs], and as recently noted [1] these themes are not new but to address them requires appropriate resourcing of maternity services in the widest sense in addition to changing longstanding cultural issues.
Adverse perinatal outcomes can occur without warning and despite good care. Incident and case review should be part of routine clinical governance procedures, but are often of poor quality and do not engage the appropriate professionals within the multidisciplinary team [2]. Learning is therefore either not identified or subsequently not embedded into practice. It is in this arena that external peer review would be beneficial.
External peer review was recommended in the Perinatal Mortality Review Tool’s first report [3] to ‘provide a ‘fresh pair of eyes’ to the review of the care provided and to provide robust challenge where complacency or ‘group think’ in service provision, as identified in the Kirkup report, has crept in.’ This has further been reinforced by the recently published Ockenden report ‘External clinical specialist opinion from outside the Trust (but from within the region), must be mandated for cases of intrapartum fetal death, maternal death, neonatal brain injury and neonatal death’ and ‘[critical] oversight [of patient safety] must be strengthened by increasing partnerships across Trusts within local networks of neighbouring Trusts.’ [4]
We believe that external peer review should be from outside of the local network, particularly when seeking to review complex neonatal or obstetric care that may only be delivered in one centre in any particular network. Over the last 4 years we have undertaken reciprocal peer mortality review of neonatal cases in the Royal Victoria Infirmary, Newcastle upon Tyne and the Royal Jubilee Maternity Hospital, Belfast. In-person attendance at case reviews has moved on-line since the Covid pandemic and we have had to address the challenges of sharing patient notes in a virtual environment.
We have learnt that:
• External opinion is a powerful tool for influencing change, for example raising awareness of staff shortages or building the case for more allocated Consultant time for service provision.
• External review can, where appropriate, reassure that practice is acceptable.
• External review can help improve the overall review process, for example by suggesting input from other specialists.
• The volume and depth of learning from those cases with external review appears to be higher compared to those without. This may be due to case selection or to the richer discussion that comes from a more diverse group. We have identified learning that would not have otherwise occurred. Importantly there has been reassurance that the local teams are not providing care or performing reviews that are influenced by ‘group think’.
• Even when external (to network) reviewers are not present, case review processes have become more robust and generate richer discussion and outputs.
• This process could be readily adapted for use in many other healthcare settings.
For external peer review to be of benefit requires appropriate resource allocation, from administrative support to ensure notes are available, to adequate IT facilities and recognition of the formal time commitment required to undertake this critical activity for all members of staff. Failure to implement this process would lose a major opportunity to improve the quality of care.
References
1. Knight M, Stanford S. Ockenden: another shocking review of maternity services. BMJ 2022;377:o898.
2. Independent review of neonatal services at Prince Charles Hospital. Welsh Government. 2022. https://gov.wales/sites/default/files/publications/2022-02/independent-r... (accessed 07/06/2022).
3. National Perinatal Epidemiology Unit. Perinatal Mortality Review Tool: Frequently Asked Questions. 2018. https://www.npeu.ox.ac.uk/pmrt/faqs#membership-of-the-local-pmrt-review-... (accessed 07/06/2022).
4. Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust. 2022. https://assets.publishing.service.gov.uk/government/uploads/system/uploa... (accessed 07/06/2022).
Competing interests: No competing interests