Time lessons are learned, and mistakes not repeated says RCM as its launches new safety series

on 24 May 2021 Pregnancy Midwifery Midwives Specialist Midwives Student midwives RCM RCM Member Maternity Services Maternity Safety maternity care assistant Multi-disciplinary care

'Learning lessons from both failed and successful maternity services is crucial to ensure mistakes are not repeated and good practice is shared'. That is the message from the Royal College of Midwives (RCM) as it launches the first installment in a new series on safety in maternity services.

The RCM’s new Solution Series is aimed at supporting midwifery leaders and midwives to implement recommendations laid out in the Ockenden Review to improve the quality of care they are delivering for women and their babies.

The College says safety must be everyone’s business and change needs to happen at pace at local level in addition to system-wide changes.

In monthly installments from May to November, the RCM will publish guidance on how to develop systems for thorough investigation following adverse events so lessons can be learned, and future incidents avoided This will include guidance on interpreting electronic fetal monitoring, leadership and creating a positive work culture.

Commenting; Dr Mary Ross Davie, the RCM’s Director for Professional Midwifery, said:

“The detailed reviews of maternity services across the UK, and including the most recent Interim Donna Ockenden review, have highlighted worryingly similar serious failings that must be addressed. As the largest professional body for midwives in the UK, the RCM has a duty to support midwives to be the best they can be – but we also know that it can be challenging knowing where and how to start. This Solution Series is an opportunity for us all to start - as organisations, as midwifery leaders and as midwives - as we seek to improve the quality of care in maternity services. We know some of this work has already been actioned and is underway which is positive. The aim of our Solution Series is to support maternity services to improve implementation and each publication will include evidence-based advice, with a focus on learning lessons not only from failed services, but also on what can be learned from successful services.”

In this first publication the RCM has examined and highlighted the topline focus and priorities for services, as outlined in the reviews undertaken by Dr Bill Kirkup in Morecombe Bay, Cwm Taf in Wales and the most recent review into maternity services at Shrewsbury and Telford by Donna Ockenden.

The RCM says underpinning the ability of any maternity service to provide consistently safe, high quality maternity care is safe staffing. All maternity services must have robust approaches to ensuring that their midwifery and obstetric staffing levels are right for their particular setting and meet national standards.

Mary added:

“Each maternity service leader has a responsibility to monitor staffing to ensure the unit is safely staffed. In reality we know that some services, particularly during the pandemic, struggled due to existing staff shortages and staff off sick or shielding due to COVID-19. Safety has to be everybody’s business and any member of maternity staff that has concerns about safety or staffing issues that are compromising safety must escalate their concerns immediately to their manager.”



To contact the RCM Media Office call 020 7312 3456, or email [email protected]


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The RCM is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team. We provide workplace advice and support, professional and clinical guidance, and information, and learning opportunities with our broad range of events, conferences, and online resources. For more information visit the RCM website.