Clinical Governance

The Network has an established and well-defined programme for discussing and reviewing issues relating to Clinical Governance. We facilitate quarterly Network meetings that focus on two main areas;

1. Learning outcomes that have arisen as a result of baby death reviews at each Trust/Unit in the previous quarter following a Multi Disciplinary Team (MDT) meeting. Clinicians and senior nurses/managers also present recent “cases of interest” that are anonymised and then discussed in a peer review environment. This allows for dissemination of “lessons learned” across all our Units and where appropriate or necessary, further work to be undertaken, such as drafting new guidelines or agreeing standardised approaches to care if/where appropriate. This also meets the aims of a plan that was agreed with NHS England to try and improve mortality rates as reported in the annual MBRRACE-UK reports. All Units are expected to feed back their learning outcomes for wider dissemination and present cases from time to time.
2. There are also opportunities to focus on other clinical governance issues, actions taken in response to local incidents (including Serious Untoward Incidents – SUIs) with action points collated and shared across the Network.

In addition, the Network also operates a “rapid response” system for Clinical Governance above and beyond local/Trust policies so that serious issues and/or untoward incidents can be communicated via the Network to enable an update to be sent to all Units, providing them with information so they can undertake internal reviews and thus minimise the risk of further re-occurrence.