Perinatal Adverse Event Reviews

SPN SAER Scoping Exercise
In August 2022 the SPN team wrote to Chief Executives, Medical Directors and Nurse Directors to advise they would soon be approaching senior midwifery, neonatal, and obstetric colleagues to discuss current perinatal SAER processes. Over 100 senior perinatal colleagues participated in a scoping survey and subsequent MS Teams meeting about strengths and challenges of local approaches and where national approaches could be most useful. Scoping meetings started with NHS Fife in November 2022 and concluded with NHS Lothian in August 2023.

Read about our findings in the new SPN SAER Group Scoping Report (Dec 2023)

Background

On 15 September 2021 the Scottish Government published “Maternity and neonatal (perinatal) adverse event review process: guidance” as an operational guidance supplement to the Healthcare Improvement Scotland (HIS) 2019 “Learning From Adverse Event Review National Framework for Scotland“. The new guidance was developed in recognition that maternity and neonatal (perinatal) reviews have additional requirements to achieve delivery of the national HIS framework, such as compliance with Perinatal Mortality Review Tool guidance and timelines.  Watch the (2021) MCQIC Perinatal Mortality Review Tool webinar here. Dr Corinne Love and Dr Edile Murdoch launch the new Perinatal guidance at 46:40 in the video.

Supporting the New Perinatal Guidance

In December 2021, the Scottish Government commissioned the SPN to support the perinatal community to implement the new guidance in five ways (detailed in SG perinatal SAER guidance section 4.c.6 Capturing and sharing learning from adverse events):

1. Develop a ‘safe space’ learning forum on MS Teams and a corresponding ‘collaboration space’
2. Facilitate regular case review events at which Boards can present, discuss and share learning (quarterly or 6-monthly)
3. Facilitate tailored learning opportunities, as requested, following particular incidents or events.
4. Develop a process to ‘Buddy-up’ smaller with larger Boards for peer support and to add structure to request for external reviewers.
5. Establish a perinatal SAERs working group through which to support implementation of the framework, provide peer support, and share learning and best practice.

As work on these 5 SPN outcomes progressed, it became increasingly clear that collaboration alone would not result in national consistency. The parallel workstreams being delivered by multiple strategic partners also required national scoping and co-ordination, including:

• HIS Adverse Events network around broader national processes and structures
• NHS Education for Scotland (NES) and Effective Communication for Healthcare (EC4H) around training and education for staff involved in event processes
• Scottish Patient Safety Programme (SPSP) Perinatal (previously MCQIC) which leads work around reducing stillbirths, maternal deterioration, variation in caesarean section and reducing neonatal mortality and morbidity
• National Bereavement Care Pathways Scotland (NBCPS) around pregnancy loss, termination, stillbirth, neonatal death and sudden unexpected death in infancy (SUDI)
• Sands around communicating with bereaved families
• Project ECHO on how Involving patients and families can improve the quality of a review and learning shared. Research into what ‘good’ patient and family involvement in healthcare adverse event reviews looks like was published by the team in the BMJ in 2022.

Adverse Events Framework Revision

Work began in October 2022 to revise the current national AE framework. 14 Focus groups took place during Summer 2023 and the outputs can help inform the review of the Maternity and neonatal (perinatal) adverse event review guidance alongside the SPN scoping work. The overarching framework revision focuses on these key areas.

• Patients, families and carers at the centre of the review process
• Psychological safety of staff – Support systems
• Timeline of commissioning, the review and sign of SAERs
• What does a quality national SAER report look like
• Systems for learning

This work continues to develop via the adverse events network which meets every 2 months. It is anticipated that the Maternity and Neonatal (perinatal) adverse event review guidance will be an additional supplement to the revised AE framework. Timescales for delivery are uncertain due to organisational re-structure within the Quality Assurance and Regulation Directorate at HIS. However, the work has a commitment from all NHS boards to collaborate towards a national approach and will be prioritised. Laura Brown has been invited to sit on the adverse events network to support communication flow and collaboration.

Healthcare Improvement Scotland (HIS) Learning systems – Adverse Events Community of Practice (CoP)

A new SharePoint Adverse Events (AE) CoP, hosted on MS Teams, piloted in May 2022. It includes a collaborative AE toolkit, hosts meeting and event documentation, and an NHS board discussion space where risk and governance leads can ask questions and share ideas and knowledge about their local processes and experiences.

On 30 November 2023 the national AE learning platform will be launched as the central hub for the site. Each NHS board will have ownership of its own area of the site. Learning summaries will be uploaded to encourage national learning alongside other  information which may be of interest to other boards.

Work of the Scottish Fatalities Investigation Unit (SFIU) (where HIS complete a learning summary at their request for specific cases where a discretionary FAI is being considered) will also be shared on this site. Learning sessions and case discussions groups/webinars are also planned with the AE network and beyond.

Work is underway with other organisations, such as COSLA (National Suicide review process) and SPN, wishing to have  workspace on the new site. This site is available to staff with an NHS e-mail address with membership access agreed by the AE team at HIS

NHS Education for Scotland (NES) – Education and Training

In response to perinatal guidance section: 4.b.5 Supporting staff training and wellbeing, NES provides resources for NHS staff involved in adverse event reviews and those in leadership/management positions.  They include learning from safety incidents in complex care environments and building a safety culture and other associated areas. Find details on the Patient Safety Zone on TURAS Learn. NES also provides:

• The Human Factors Hub which will contain a range of new learning resources and courses (face-to-face, online and hybrid).  Some of this is in the development and testing phase.
• Safety Investigations and Learning Reviews– this contains a range of learning resources including capturing organisational learning and systems thinking for safety investigation.  The latter will contain a range of material to support those conducting investigations and learning reviews and is currently in development.
• Brief introduction to Human Factors
• Learning at work week- What is Human Factors?
• What is Systems Thinking
• ‘Why things go wrong and right in complex systems’ e-module
• an Enhanced Significant (learning) Event Analysis (SEA) e-module
• entry-level Human Factors e-modules
• a Duty of candour e-module (which includes a ‘train the trainers’ component)

In addition to training, appropriate measures must be in place to support the wellbeing of staff during and following involvement in an adverse event review process. It is possible this support could be provided through future collaboration with NES and/or EC4H