Review into adverse events in maternity

Families offered role in overseeing improvement work.

Families will be offered a key role in overseeing the implementation of recommendations from an independent review of adverse events at Ayrshire Maternity Unit, Health Secretary Shona Robison has confirmed.

Delivering a statement to parliament on the Healthcare Improvement Scotland (HIS) report, published today, Ms Robison apologised to the families affected, and assured them all recommendations will be implemented in full.

The report makes eight recommendations for improvement, six of which are for NHS Ayrshire and Arran, focused on:

  • Changes to the adverse event review process
  • Improved family engagement and communication
  • Improved support for staff, including protected training time
  • Promotion of shared learning internally and externally
  • Revised procedures for publication of reports
  • Improved identification of and access to training for staff

One recommendation is about ensuring that staff have the ongoing skills and competencies to deliver safe care. We will work in partnership with Health Boards  to agree a core mandatory update training programme for maternity staff before the end of the year.

HIS have been asked to feed the learning into their new Quality of Care review processes which will be rolled out across Boards from this Autumn.

NHS Ayrshire and Arran also commissioned an independent team of experts from the University of Leicester to review the clinical care in a number of recent cases of stillbirth or neonatal death. 

Of the cases examined, they found that a number might have had different outcomes with differences in care. The report made several recommendations for NHS Ayrshire and Arran focused on quality of care, staffing and improvement activity in the unit. 

Health Secretary Shona Robison said:

“Earlier today I spoke to the vice Chair of NHS Ayrshire and Arran and made clear that the sub-standard practices uncovered in these reports are unacceptable. NHS Ayrshire and Arran have apologised to families and I want to extend my personal and sincere apologies.

“The Board have today published an action plan that outlines how they will take forward these recommendations. I welcome that and I will seek regular updates on implementation. 

“I have offered to meet all of the families affected by these extremely sad cases. In recognition of the work they have done to raise awareness of these issues, I will also be offering them a role on a new stakeholder oversight group, along with representative organisations, that will be established to oversee these changes.

“HIS have confirmed that they will action the recommendation for them, and that they will monitor and support the progress towards the implementation of the Board’s recommendations every three months in the first instance. 

“Every case of stillbirth and neonatal death is a tragedy for all concerned, and it’s vital that we learn lessons from every one. However, it is important to note that the rate of stillbirth and neonatal death continues to fall and in 2015 we had a record low rate for Scotland.

“Following our review of maternity and neonatal services the Best Start report, published earlier this year, uncovered a range of evidence of good practice in Scotland. Implemenation of the report’s 76 recommendations is underway and will deliver safer, higher quality maternity care for women and babies.”


The Cabinet Secretary’s full statement to parliament (27 June 2017) is available here.


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