[A] special report detailing the progress made to implement the recommendations of the Report of the Morecambe Bay Investigation (Kirkup Report) has been presented to the Trust Board of University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT).
The Kirkup Report was published on 3 March 2015, and made 44 recommendations in total – 18 of which were for the Trust to address across its hospitals, with the
remainder being for the wider NHS. The recommendations varied in nature including reviewing the skills, knowledge, competencies and professional duties of care of certain groups of staff within Women and Children’s and critical care services; meeting any identified training needs from the review; and identifying and developing measures to promote effective multi-disciplinary team-working.
Since the Report was published, staff from across the Trust have been working hard with stakeholders, service users and members of the public to address each
recommendation in full. Good progress has been made, and to date, the Trust has met every timescale stated. It also remains on track to deliver the remaining
recommendation on time, which is to improve the physical environment in the Labour Suite at Furness General Hospital (FGH) by December 2017.
The ‘One Year On – How we implemented the Kirkup Report’ document provides:
- A summary of the work carried out for each recommendation, including the associated cultural changes and learning opportunities
- Details of any work that will continue as part of the Trust’s ‘day-to-day’ activity, and how it will be continuously monitored
- Information on the learning that is being taken forward throughout the organisation
Jackie Daniel, Chief Executive, UHMBT, said: “The publication of the Kirkup Report was a watershed moment, not just for the Trust but for those families and
communities that have been so tragically let down by past failures.
“It was important that we didn’t just treat the recommendations as a ‘check list’ of actions, because we owed it to everyone involved to demonstrate we would truly
learn from it.
“Our ‘‘One Year On’ How we implemented the Kirkup Report’ document contains many instances of changes and improved practice, examples of innovative
approaches to the problems of our particular geography, and describes how we viewed the recommendations as the starting point for change, not the end point.
“It would be easy to just focus on the big ticket items, such as the approved plans for a new £11m Maternity Unit at Furness General Hospital FGH), but a tremendous amount of work has taken place in all areas to meet the recommendations so far, and I’d like to thank the staff, stakeholders and service users for their support. A special thanks needs to go to those families who lost loved ones that have supported us throughout – your bravery and commitment to helping us to improve things further for the benefit of local people have been inspiring.
“Whilst I am pleased that we have met all the recommendations so far, there is still a lot of work still left to do. Our strategy is one of continual improvement, and I look forward to sharing updates on further progress throughout the year.”
The report highlights many areas where the Trust has made improvements and changes, including:
Engagement: Services users, members of the public, and families who have lost loved ones have been at the heart of the improvements in maternity services, and have been actively involved in the changes, including: reviewing clinical guidelines; helping to write job descriptions; sitting on interview panels for new staff; and helping to develop plans for the new Maternity Unit at FGH.
Governance: More staff now are able to describe how to report incidents, with a recent internal survey showing that 93% of the staff asked know how to report a patient safety incident. There was also a 12.58% reduction in complaints in 2015/16 compared to 2014/15 – against a target of 5%. This was down to investment in the Patient Advice and Liaison Service and further training meaning issues were being resolved at ward level rather than patients and families feeling they have to submit a formal complaint.
Cardiomyopathy conference: The Trust worked with a local mum who tragically lost her daughter to Cardiomyopathy shortly after giving birth to organise a study day for UHMBT staff to raise awareness of the condition in pregnancy and the signs to look out for. National charity Cardiomyopathy UK supported this event and on the back of feedback from those that attended, has committed to a number of things, including the development of a resource centre for midwives on its website.
Strategic partnerships: The Trust has set up strategic partnerships with both Central Manchester University Hospitals NHS Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust, to share best practice and learning. This also includes the opportunity for staff from the Trust’s Women and Children’s Division to attend teaching courses at the partner Trusts and in some cases, undertake placements.
Training and development: Every member of staff in the Women and Children’s Division and Critical Care teams now have an individual electronic training record that clearly sets out the training and learning that they are required to undertake as part of their role. This will be rolled out to all UHMBT staff by the end of March 2017.
The publication of the report comes as the Trust Board approves the recommendation to formally ‘step down’ the Trust’s internal Kirkup Programme, which included the formation of a special Sub-Committee of the Trust Board and Working Group to oversee the work.
Dr David Walker, Medical Director, UHMBT, said: “The ‘stepping down’ of our Trust Kirkup Programme is by no means the end, and it should not be interpreted that we think all the work to improve is complete.
“The specific project structure and governance arrangements we put into place to respond fully to the Kirkup Report, were always intended to be short term. This
allowed us to put the resource and focus into doing what needed to be done in the best way we could to meet the recommendations in the timescales given.
“We have now implemented all the recommendations in full, with the exception of the new Maternity Unit at FGH by December 2017. This means that this specific project structure is no longer needed. The remaining recommendation and the continued monitoring of the changes and improvements to ensure they are sustained will now be done as part of normal Trust ‘day-to-day’ activity through our existing governance structures and committees.”
The full ‘‘One Year On’ How we implemented the Kirkup Report’ document can be found on the Trust’s website at https://www.uhmb.nhs.uk/about-us/key-publications/.