Safe Births: Everybody’s business: An independent inquiry into the safety of maternity services in England from the Kings’s Fund makes the following recommendations:

• Teams themselves should:
  • agree safety-focused objectives
  • identify clear roles and responsibilities
  • utilise clear communication standards and protocols
• Safety should be placed at the heart of shared objectives for maternity services in quality joint working The Royal College of Midwives (RCM) and Royal College of Obstetricians and
• Regular reviews of demand and staffing should be conducted with an emphasis on deliveringthe right skill mix todeliver safe services
• Trust boards and managers should regularly receive information employment levels, skill mix and deployment achieved across all shift.
• Simple and effective tools to help maternity managers to manage employment and deployment, to map demand, capacity and patient flow and to provide timely feedback on levels achieved across all shifts and locations should be developed using work used in other specialties.
• A designated maternity unit manager should keep information on all training completed and planned.  Managers and Boards should reveive regular reports on training.
• RCOG, the Nursing and Midwifery Council (NMC) and the Postgraduate Medical Education and Training Board (PMETB) should spread expertise on skills training and emergency drills to all maternity units by adapting elements of existing simulation based training models and turning them into high-quality training tools that can be
  used locally at minimal cost and disruption
• Safety awareness training must be mainstream professional education at all levels.
• A single set of evidence-based guidelines that are backed by professional organisations, National Institute for Health and Clinical Excellence (NICE) and other organisations shoulddeveloped.
• Guidelines must be supplemented by short one page summaries and usable, consistent protocols.
• All disciplines should be encouraged to familiarise themselves with using guidelines in a local setting and should be trained to use the relevant protocols.  Their use should be regularly audited.
• Annual evidence digests and a national briefing system, tools like Map of Medicine should reinforce use of guidelines.
• A small set of reliable, safety-critical information measures should be collected.
• Simple systems for capturing local information on safety should be designed, implemented and maintained locally.
• Boards must prioritise safety, communicate that to staff and patients and make data on safety publicly available.
• Board members should be trained to strengthen advocacy for maternity safety.
• Governance structures must be in place to assure safety, this should strengthen safety committees and systems for collecting and reporting safety information.
• Regular executive walk-rounds, analysis of claims data, incident reports and other safety indicators, and by reviewing safety incidents in detail should be undertaken.
• Safety must be recognised as a business imperative.
• Standards for the safety of maternity services should be set and monitored only by the Healthcare Commission (in future the Care Quality Commission), with approarpiate advice received by professional bodies.
• Existing standards hould be distilled into a smaller number that are critical to safety, and can beconnected to data that can be collected by teams.
• Strategic health authorities and others providing regional leadership for maternity services should be primed to offer specific support to trusts undergoing reconfiguration.
• DH shouldensure financial incentives are aligned to promote the safest care and to galvanise boards into prioritising safety commissioning and patient choice should act as drivers for improvement.