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Case study: Governance

Following receipt of an anonymous letter to the GMC regarding patient safety, poor practice and flawed investigations within a Trust, we were invited to examine the obstetric and gynaecology services.

Our assessors reviewed reports and documents available within the Trust’s clinical guidance framework and specific cases involving surgical practice in gynaecology, and antenatal and intrapartum care. We also looked into issues that may have been preventing staff from raising patient safety concerns.


On completion of the two-day site visit our assessors made the following recommendations to improve safety:

  • Named Executive Director to increase awareness and compliance with the Whistleblowing Policy
  • Improve record keeping through staff training and special checks
  • Develop effective procedures to ensure incidents are reported and action taken to share lessons learned
  • Improve the rigour of their root cause analysis investigations

Elsewhere on the site

Audit & quality improvement
Find out about the College’s national audits and other projects aimed at improving the quality of women’s health services
Guidance for commissioners
Resources to support commissioners and health service managers with responsibility for commissioning high-quality women’s health care