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27 June 2017, 13:45
A review into adverse events at a maternity unit where some babies died has called for improvements in training and better family engagement.
The Scottish Government ordered Healthcare Improvement Scotland (HIS) to carry out the review last year after families whose babies died during childbirth at Ayrshire Maternity Unit spoke out about their experiences.
Between 2008 and March 31 last year, there were four significant adverse event reviews concerning stillbirth deaths at the unit at Crosshouse Hospital, Kilmarnock, East Ayrshire.
A BBC investigation found there have been six so-called ''unnecessary'' deaths of babies at the hospital since 2008.
The most recent review was set up to look at the management of adverse events from December 2013 onwards and found staff were unsure how to respond to an adverse event once it was initially reported.
It found the maternity unit "circumvented deficiencies in the NHS board's adverse event management policy in order to maximise local clinical engagement in reviews''.
NHS Ayrshire and Arran apologised to the families involved and said it is committed to continuous improvement.
HIS has recommended the health board strengthen its current adverse event management policy so it can be "quickly and simply followed''; improve family engagement to involve them more in the response to serious events, and to support staff in the management of adverse events across the maternity unit.
Dr Tracey Johnston, chair of the independent review group, said: "In preparing this report, we heard from families devastated by the death of their baby around the time of birth and I thank them for having the strength to come and talk to us.
"Their narratives gave us insights we otherwise would not have had and strengthened the review by enabling us to explore specific areas with the staff at Ayrshire Maternity Unit.
"This report, combined with the clinical case review, provides a full picture of care in this unit.
"We found the team at Ayrshire Maternity Unit to be a cohesive and highly-motivated team with strong leadership, committed to providing high-quality care to those they look after. We saw some examples of good use of learning and improvement.
"However, there are clearly lessons to be learned from this review, not just for NHS Ayrshire & Arran but for Scotland as a whole.
"These lessons, through the recommendations of this report, should be embraced as ways to learn from such serious cases and improve care across NHS services.''
The health board is creating a risk and quality improvement team to focus on adverse event management.
John Burns, chief executive of NHS Ayrshire and Arran, said: "Perinatal loss and stillbirth is a tragedy and I would like to offer my apologies to the families affected by and involved in this review.
"I also thank them for sharing their experiences with HIS. I appreciate how difficult it must have been for these families to revisit such painful and distressing memories.
"During 2016, NHS Ayrshire & Arran's maternity services were subject to three reviews, two of which were commissioned by NHS Ayrshire & Arran.
"This was in response to concerns around our perinatal mortality rates as published by MBRRACE* for 2013-14.
"These reviews demonstrate our commitment to ensuring the provision of a safe and caring maternity service, delivered through our clinical teams.
"NHS Ayrshire & Arran has a commitment to continuous improvement.
"We have confidence in the safety of our maternity services and in the contribution that our staff make towards providing high-quality clinical care, governance and learning.
"We value scrutiny and inspection of our services as a learning organisation.''