Greater Manchester Lancs & South Cumbria Senate

Maternity & PMH - supporting external representation on review panels

5th April 2018

James_Boyes.jpgNetwork Quality Improvement Programme Manager, Dr James Boyes, spoke recently at the Each Baby Counts: Two Years On national conference about how the SCN has been supporting its trusts to secure external input to their Each Baby Counts Root Cause Analysis (RCA) review panels.

Below, James summarises the process and highlights some of the primary barriers we have identified through our work to date.

When a review is called, the host trust contacts the SCN to let them know when and where the panel is being held, the broad nature of the incident (e.g. an intrapartum stillbirth) and the type of external input being sought – for example midwifery, obstetric and/or neonatology input. To support that process the SCN holds a database of clinicians from across the region who have expressed an interest in supporting these panels. The database is regularly refreshed to take account of movements in staff across the network footprint. 

The SCN’s Special Interest Groups are used to gain commitment to the process, with the Management & Reduction of Stillbirth Special Interest Group playing a key role. Once external clinicians have been identified, the SCN forwards their details onto the host trust and they then coordinate their involvement in the panel itself. This approach ensures that trust governance processes are supported because no patient data is shared with the network. Once the review panel has concluded, the trust works with the SCN to produce an anonymised summary of the lessons learned from the incident. This template is also used for other relevant non Each Baby Counts reviews. The completed templates are fed into the appropriate Special Interest Group for discussion, before being fed into the region’s Maternity Clinical Experts Group for further dissemination. 

The SCN also holds regular Study Days where these cases are analysed for common themes which form the basis of directed improvement work. Last year almost 30% of the region’s Each Baby Counts panels had external representation. Improving this figure will involve further awareness-raising of the process to increase the number of requests for representation being made, along with increasing trust level commitment to the process – for example, supporting clinicians to attend the reviews.  

The Maternity and PMH Network’s work to date has highlighted that barriers include:

  • Raising awareness of the process for arranging representation
  • Engagement with trusts to request representation
  • The time pressures set by external bodies for completion of the report
  • The time required for review
  • Managing voluntary representation at reviews
  • Managing conflicting priorities within the trusts.

More information

To find out more, please contact James at or Julia Charnock at

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