Learning to lessen risk

By Catherine Doherty on 26 November 2010 Midwives Magazine Postnatal Care

Clinical risk facilitator and midwife Catherine Doherty offers advice on managing risk in maternity services and achieving accreditation for the Clinical Negligence Scheme for Trusts (CNST).

Midwives magazine: December 2010

Earlier this year, an NHS trust was ordered to pay £100,000 after its failure to manage the risk of drug errors led to the death of a new mother, when a midwife mistakenly administered an epidural anaesthetic via an intravenous drip rather than saline solution. The case illustrated the vital importance of avoiding mistakes by controlling risk effectively. The substances had been mixed up as they were in similar packaging, in the same cupboard, and the trial concluded that avoiding ‘any one’ of a number of errors would ‘probably have averted’ the woman’s death (Health and Safety Executive, 2010).

Prosecutions and claims for medical negligence have escalated and are still on the increase (CNST, 2009), which has a knock-on effect on services because resources that could have been used for client care are diverted to settle claims. 

Risk management is the lynch pin that pulls together all the different sections of clinical governance. It is a systematic process of identifying incidents and near misses, so when things go wrong, lessons can be learnt to improve clinical practice and provide explanations and answers. Safety is the top priority in clinical care (National Patient Safety Agency, 2004).

Over the last 20 years, there has been an improvement in care quality and standards, dramatic advances in technology, and a noticeable rise in public expectations. The public expect pregnancy and labour to be straightforward and so, when complications occur, their initial reaction is to assume health professionals have made a mistake and to demand an explanation.

There is pressure on the NHS to perform, which partly comes from a user’s right to complain with the possibility of it leading to litigation. But risk management is not only concerned with a reduction in lawsuits, it should be seen as a proactive way to prevent and reduce poor outcomes.

National confidential enquiries have highlighted areas of sub-optimal practice and made lots of recommendations. Many of the poor outcomes identified could have been avoided if only lessons were appropriately learnt. 

Risk is everyone’s responsibility and risk assessments should be part of everyday practice. It is not a new concept; clinicians have always assessed risk. But in today’s climate, it is essential to have a robust system in place, which addresses risk management and supports the multidisciplinary team.

With government initiatives and the need to meet targets, it’s important practitioners are aware of the need to report all accidents and incidents, and are seen to be proactive rather than reactive. Most staff are aware of the relevance of risk management to their work, but may feel accountability and responsibility for risk fall solely to the risk manager. One major lesson for clinicians is that risk management is a process, not a position.  

Supervisors of midwives (SoMs) and the clinical governance lead play an important role in risk management, by not only working within the clinical governance framework, but also with the maternity risk manager, supporting all staff and ensuring the service maintains good practice.

An organisation needs to have a clear review mechanism for it to adopt an open and fair blame culture. It was previously named a ‘no blame’ culture to encourage staff to report incidents without fear of reprisals, but this didn’t always work so a ‘fair blame’ culture was developed, enabling staff to share their experiences, learn lessons on improving client care and create a positive safety culture.  

When there has been an incident or near miss, it is essential to analyse root causes across all services to identify areas for improvement and prevent unnecessary changes in practice. If incident analysis identifies training or practice issues, then prompt action should be taken. It is important staff receive feedback to ensure lessons are learnt. 

Trigger lists are an essential part of incident reporting because there is no guarantee information will be cascaded. It is difficult to think of incident reporting in the middle of a short-staffed and busy ward, but it is important the team detects under-performance and resolves it at an early stage by escalating issues to senior management and SoMs.

Supervision plays an important role in incident investigation, as a supervisor can advise staff and employers and promote good clinical practice. If there is a serious untoward incident (SUI), it is imperative an identified SoM and all senior staff are available to give support and actively listen to those who were directly involved.

The service should arrange an open discussion meeting so personnel involved in the case can clarify issues, and identify good and bad practice. The team should devise an action plan with time scales to implement lessons learned from the incident. Any changes to clinical practice should be audited to make sure it’s improved and has not introduced any unforeseen risks.

The RCOG Maternity Dashboard, developed in 2008 to help maternity units plan and improve services, is a useful tool for clinical governance, as it allows the team to identify trends, shortfalls and plan action. Also referred to as a clinical performance and governance scorecard, the dashboard monitors the implementation of local targets and principles of clinical governance on the ground, helping identify patient safety issues in advance so that appropriate action can be taken. 

To promote risk management standards and manage litigation claims against the NHS, CNST maternity standards replaced previous standards in April 2009. The standards can be adapted to specific services, and a CNST assessment is used to audit them. 

When priming a maternity unit for a CNST assessment, preparation is paramount. The process should include:
✼ Planning and team work to gather appropriate evidence
✼ An informal visit from the assessor to gain guidance
✼ Reviewing the standards, ensuring all evidence is relevant
✼ Regular communication with the assessor and other units
✼ Identifying and cross-referencing relevant case notes
✼ Correlating evidence and putting it into the CNST template, which will form the foundation for the assessment.

With continuous education and promotion, risk management will eventually become part of everyday practice. By working together to break down barriers to effective risk management, and committing to a culture of openness and honesty, maternity services can improve care by assessing and reducing risk.


Clinical Negligence Scheme for Trusts. (April, 2009) Maternity Services Risk Management Standards (NHSLA). See: www.nhsla.com/riskmanagement (accessed 25 November 2010).

National Patient Safety Agency. (April 2004) Seven Steps to Patient Safety: An Overview Guide for NHS Staff. See: www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/ (accessed 25 November 2010).

RCOG. (January, 2008) Maternity Dashboard: Clinical Performance and Governance Score Card (Good Practice No 7). RCOG: London. See: www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card (accessed 25 November 2010).

https://nds.coi.gov.uk/content/detail.aspx?NewsAreaId=2&ReleaseID=413367&SubjectId=15&DepartmentMode=true (accessed 18 November 2010).