The delivery of safe care is an overarching theme in all the reviews. During one review the RCOG team identified that although systems were in place to support clinical governance, and safe and effective practice, they were not functioning. They were difficult to use and did not support front line care.
In addition the incident reporting system was not utilised to its full potential and the range of incidents reported were mainly concerned with low level facility and process issues rather than clinical incidents. Moreover, no one was able to identify any learning which had come about
from the incident reporting or complaints processes.
Our recommendations included:
- A review of the use of the incident reporting system
- Development of a system to produce a reasoned response to incidents
- Using the outcomes from incidents and complaints as learning and developmental tools
- An agreed plan for governance and joint working needed to be developed and supported by all professional groups