The review identified a number of concerns at the trust particularly related to the quality governance assurance systems.

The review panel also identified a number of areas of good practice and dedicated staff, but there was more for the trust to do to communicate effectively to staff and share learning to ensure consistent approaches to quality improvement across the organisation, all of the time.

Issues that were escalated immediately:

  • The panel identified that there had been a high level of still born babies in March 2013 but this had not been escalated to the board or investigated. The trust has is now investigating this and is setting clearer procedures for triggering escalation.
  • The review team also expressed concern over the appropriateness of the location of two close observation beds (referred to as high dependency beds by some staff) in the Delivery Care Centre in the maternity unit, which were used for pre- and post-delivery pre-eclampsia. This is being reviewed urgently by management.

Other urgent actions:

  • The board’s quality governance processes were not cohesive and failed to use information effectively to improve the quality of care.
  • The governance systems are not providing the expected level of assurance to the board, and the escalation to the board of risks and clinical issues is inconsistent.
  • Managing high patient levels, particularly in A&E, and understanding and addressing the issues causing high readmission rates of patients treated in the trust’s hospitals.
  • The trust’s complaints process was poor and lacking a compassionate approach.

The review team considered that staffing levels were low for medical and nursing staff when compared to national standards. Particular issues should be addressed regarding registrar cover and medical staffing in the emergency department, and levels of midwifery staff.

Certain clinical concerns raised by staff have not been addressed, including known high mortality at the weekends.

Whilst some of these actions will take longer to address entirely, assurance in respect of patient flows in A&E and concerns over staffing in the midwifery unit had already been sought by the Care Quality Commission.

Follow-up action:

The trust has responded positively to the review process with some urgent issues already addressed, for example, the establishment of a multi-professional Mortality Steering Group. The trust is working very closely with the TDA and others to address the other key priorities.

The trust will develop a detailed action plan, working with the TDA, to all outstanding concerns and recommended actions included in the RRR report. A follow up risk summit will be held in September 2013 to monitor progress and provide an updated action plan for ongoing review and monitoring arrangements.