Friday 03 October 2014
The Board and staff at the Health and Social Services Department are committed to investigating the circumstances that led to the tragic death of a new born baby earlier this year.
First of all, we offer our heartfelt condolences to the family who lost their baby. We are very mindful of their request for privacy and we will not be giving any information about their identity. We will continue to provide all of the support and information that the baby's family ask for and need.
It is absolutely vital to do everything that we can to deliver the best possible outcomes for mothers and their babies across the Bailiwick and for the public to have continuing confidence in the quality of our maternity services, and we are working with external authorities to ensure that Islanders can have maximum reassurance.
This matter is being taken extremely seriously. We are investigating what happened with the greatest care and scrutiny and with the assistance of independent external experts. We are also focused on doing everything possible to minimise the risk of the circumstances that led to this tragic incident ever happening again. The public and HSSD must be absolutely reassured that all the necessary systems are in place to provide consistently excellent clinical care across our maternity services.
We have responded by taking immediate precautionary actions. Some of the changes that have already been put in place are:
- There are now four midwives on every shift one of whom will be a midwifery clinical lead. Previously there were three midwives on every shift.
- Therefore, there are now five midwifery clinical leads working on Loveridge Ward and another of these posts is currently being recruited to. These clinical leads will provide senior management, co-ordination and support. Their responsibilities will include risk management, clinical governance, training, development of services and practical clinical support.
- A Supervisor of Midwifery will be starting this month for six months. There is now in place 24/7 supervisory support from Jersey, and discussions are on-going regarding an on-island presence.
- The working patterns of obstetricians have been changed on a trial basis and will be subject to ongoing review.
- The way that medicines can be sought and agreed for administration during labour has been changed.
- Appropriate safeguards have been put in place but we cannot discuss individual employment matters
An extraordinary review of midwifery supervision in Guernsey took place this week. It was commissioned by the Nursing and Midwifery Council and focussed on the quality of supervision of midwives and compliance with the Midwives rules and standards (2012).
All relevant staff within HSSD ensured that we supported and co-operated fully with this review, which will reach its conclusions and a written outcome in a timely manner. This report will be published by the NMC when completed, and HSSD will be required to take appropriate action in accordance with the requirements of the findings.
In addition, the Department is liaising with two of the relevant regulatory bodies - the General Medical Council (GMC) as well as the NMC - on the terms of references for a further HSSD-commissioned wide ranging review of maternity services in the Bailiwick to include maternity services encompassing obstetric and paediatric practice. This review will include an examination of the quality of clinical practice, local policies and procedures, leadership and management and the culture around how the system is working in Guernsey. All doctors have to be registered with the GMC and must have a license to practice issued by them. All nurses and midwives equally have to be registered with the NMC. Both regulatory bodies set the professional standards to practice required of doctors, midwives and nurses working in Guernsey and elsewhere. By working with these two highly respected and influential bodies - and by making a public commitment to transparency about the review's findings - we are seeking to reassure everyone that we will do everything in our power to deliver the best maternity care possible.
The terms of reference for this review will be published as soon as they are finalised, and the final report will also be published, along with the recommendations and the actions that we will take.
Deputy Mark Dorey, Minister for the Health and Social Services Department said:
"Ideally the board would have liked to continue its work with the staff to ensure significant relevant improvements were made to systems of governance, supervision and regulation. But under the circumstances the board, including Deputy Brouard who recently joined, have decided to resign.
Principally, as politicians we are responsible for strategy, policy and to be accountable for the department. Recent reports on midwifery did not identify any significant problems. However as the board is accountable, this is best demonstrated through our resignations."
A Helpline has been set up to ensure that anyone with relevant questions can contact us for information or advice. The direct number to call is 707490.
Helpline Times are:
Friday 3 October 2pm until 4pm
Saturday 4 October 2pm until 4pm
Sunday 5 October 10am - 12pm
Weekdays until further notice 10am until 4pm
Local Supervisory Authority (LSA)
NHS England is the Local Supervising Authority for England and has the statutory responsibility for midwives practising within England. The Nursing and Midwifery Council (Midwives) Rules 2012 govern the framework in which midwives, supervisors of midwives and local supervising authorities meet the requirements of the Nursing and Midwifery Order 2001.
Health Profile 2010 - 2012
The infant death rate in Guernsey is low in comparison to national figures for England and Wales. On average there has been one infant death each year in the 12 years to 2012, ranging from 0 to 3 in any given year. The infant death rate for Guernsey and Alderney in the period 2010 to 2012 was 1.0 per 1,000 - significantly lower than the most recent comparison rate for England and Wales — 4.3 per 1,000.
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