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Terminology must be used in line with the relevant nhs serious incident free mark. all investigations must be undertaken by multi—professional team of investigators and never by one individual or a single profession. in view of the relatively high number of direct maternal deaths, the trust current man multidisciplinary team training for common obstetric emergencies must be reviewed in partnership with a neighbouring tertiary unit to ensure the training is fit for purpose. the trust must adopt a consistent and systematic approach to risk assessment at booking and throughout pregnancy to ensu...

They were praised for that. at the same time as their cesarean section rates were really low, part of the period under investigation, their death rate was 10% higher than other comparable trusts for maternity and neonatal care. so, it is another example, i guess, neonatal care. so, it is another example, iguess, how neonatal care. so, it is another example, i guess, how this wasn't examined properly.— example, i guess, how this wasn't examined properly. yes. what you're hittinu examined properly. yes. what you're hittin: on examined properly. yes. what you're hitting on is — examined prope...

Assessed or checked upon the trust. this was a trust with significant problems and whilst independent and external reports often indicated that the maternity service should improve its governance and investigatory procedures, this did not happen. the trust was of the belief that its maternity services were good. they were wrong. donna 0ckenden concluded by making recommendations for maternity services across england so that this didn't happen again. to harness the learning from this report and bring together other learnings from across maternity system, a working group, independent of the mate...

Trust, hoping someone would do something. fouryears trust, hoping someone would do something. four years after her death in 2006, her mother went on the this morning show, she told me that over all those years raising concerns, she felt like a lone voice in the wind. at the same time as 0livia's mother was appearing on television, otherfamily 0livia's mother was appearing on television, other family suffered the death of their babies and only then did the health care commission review the trust. it failed to take the necessary action. this was a missed opportunity for the trust to learn. the e...

Achievements of richard stanton and colin griffiths following the death of their daughters, kate and pippa, kate in 2009 and pepper and 2016, the required scrutiny has now taken place. the voices of families are now finally being heard. 0ur place. the voices of families are now finally being heard. our team want to highlight that in the eight months before baby kate died, there were two other incidents at the trust where babies also lost their lives. these babies have been named in a report and will be named today with the permission of their parents. they were called joshua and thomas. in the...