The Office of the Health Ombudsman (OHO) initiated an investigation after receiving written notification from a Hospital and Health Service (HHS) about concerns raised in an internal complaint regarding the maternity services at one of their hospitals.

Wider learnings and recommendations for service improvements

The investigation identified opportunities for improvement and proposed recommendations relating to:

• Clinical staff compliance with Maternity guidelines, pathways and policies related to clinical observations, management of pregnant women with diabetes and recognition of and responding to clinical concerns.
• Implementation and compliance with a decision/referral matrix related to women with diabetes.
• Medication safety, focusing on missed medications and on-time medications.
• Timeliness of discharge summaries and auditing discharge summary content against information in clinical records.
• Auditing written handover processes to measure compliance with the clinical handover framework.
• Improving staff access to clinical safety and quality data.
• Timeliness of clinical incident reporting, identifying and actioning opportunities for improvement.
• Trends in clinical incidents related to issues identified as part of the Maternity Services Quality Improvement Plan 2023/2024 and OHO investigation as a measure of the impacts of actions implemented on patient outcomes.