Learning lessons from both failed and successful maternity services is crucial to ensure mistakes are not repeated and good practice is shared.

The RCM’s 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.

With services facing staff shortages and immense pressures safety should be everyone’s business and change needs to happen at pace at local level in addition to system-wide changes.

In monthly installments, the RCM 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.

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. 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.

The RCM Solution Series 

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.

In this second publication the RCM offers a practical self-checklist that can be used by RCM members to reflect on whether their own service and team have the right context, capacity and capabilities to lead the maternity services effectively, with safety at the heart of decision-making.

The third publication outlines what trusts and boards can do to organise and structure their services to reduce the chances of individual error as much a s possible. It also provides a checklist for midwives and maternity support workers to reflect on how they work under pressure, with actions and practical tips to limit their chances of making an error.

In the fourth publication encourages positive working culture as a way to improve safety in services. With significant shortages of midwives, there is an even greater need to get culture right. This edition includes practical tools to help services and midwifery leaders improve culture in their services. The series also highlights studies form organisations like the King’s Fund, results of NHS staff surveys and brings together shared learning for its members.