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Serious incidents in north Cumbria maternity services prompted investigation

High numbers of serious incidents in maternity services at Carlisle and Whitehaven prompted an investigation.

There were more reported incidents at North Cumbria University Hospitals NHS Trust during 2017 and 2018 than any other trust in the north east and Cumbria.

However following a review, bosses say there were no specific reasons for the high figures.

In fact, they say the high number of reports shows that staff feel comfortable flagging up concerns, and issues aren’t going undetected.

The review was highlighted in a report to NHS North Cumbria Clinical Commissioning Group’s governing body earlier this week.

Serious incidents in the NHS are those that have an adverse impact on patients or have the potential to cause serious harm.

They are strict protocols for reporting such incidents, investigating them and learning lessons where possible.

The most serious incidents are called ‘never events’, though these are very rare.

The CCG carried out a review because the North Cumbria was the highest reporter of serious incidents in maternity, compared to others in the region.

It looked at all of the incidents reported over the past three years at the Carlisle and Whitehaven hospitals.

The CCG did not find any specific themes, but the findings have been shared across the local health system.

It concluded that proactive work to encourage staff to report incidents had contributed to the rise.

The report to the governing body said: “The associate director for midwifery reported that there had been a lot of awareness raising of incident reporting in the maternity service, and this may mean the trust now have a lower threshold for reporting than other trusts.”

Anna Stabler, director of nursing and quality for NHS North Cumbria CCG, said: “It is evident from the recent Care Quality Commission (CQC) inspection and maternity survey that patient experience of our maternity services is good.

“We commissioned this review as we noted the increase in reported serious incidents.

“Through investigation it became apparent that all serious incidents had been reviewed appropriately, involving the families affected.

“However it was clear that there were no emerging themes or trends. This indicates a workforce empowered and enabled to be open and honest.

“This review demonstrates we are vigilant to any changes and on behalf of our population we closely monitor the quality of our services.

“In this case the increase has been shown to reflect the hard work of our maternity teams and the emphasis on a learning culture.”

An overdose of insulin caused by an incorrect device has been recorded as a ‘never event’ by hospital bosses.

They stress that the patient didn’t come to any harm.

Never events are preventable incidents that should not occur.

The incident, in October 2018, is the only never event recorded by North Cumbria University Hospitals NHS Trust – which runs the Cumberland Infirmary, Carlisle, and West Cumberland Hospital, Whitehaven – in the past six months.

It was recorded in the safety and quality report, which goes to the trust board.

Alison Smith, executive chief nurse, said: “The trust has reported a never event which occurred in October 2018.

“The number of never events experienced within the trust has significantly reduced over the past three years thanks to the hard work of our staff in implementing improvements in patient safety. However, we recognise that any level of harm to our patients in unacceptable and we are continually striving to make further improvements.

“As part of our commitment to providing safe, high quality care to all of our patients, we actively encourage our staff to opening report incidents. This is because we want to ensure solutions are in place to prevent harm and after any incident occurs, we carry out a full investigation and share learning throughout the organisation.”

ENDS