Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals

Risk Register
APPENDIX 7 Version 1 new format November 2009
Sandwell and West Birmingham NHS Trust Clinical Risks for Medium Term Options
J Dunn redesign Director,G GAdd-service
redesign Manager,E Newell Head of Midwifery, P
Bosio Lead Clinician, S Murray Divisional
Manager
SWBTB (2/10) 045 (c)
Risk Area Risk Assessment Risk Owner
Risk Management
Risk Commentary
Post Mitigation Risk Assessment
OPTION Category Description Impact Likelihood Overall Risk Level Organisation Officer Advisor Indicators for Crystallisation Action to Mitigate
Date for
Review Notes Impact Likelihood Overall Risk Level
3h
Insufficient experience and skills within the midwifery 4 team for 3Stand alone 12MLU
high Delay in women receiving timely intervention
and increased clinical risks asscociated with
this situation
Careful planning with local transport networks to
ensure that appropriate transport links in place.
Positive promotion of service reconfiguration to
ensure women are aware of benefits of service.
Clear information provided to women (all
languages) regarding planned
changes.Recruitment and training of midwifery
workforce
4 2 8 medium
3i
Unfoseen emergency in labour at MLU with
need for transfer
4 4 16 high inappropriate home delivery with
clinical risks associated with this
situation
3j Increased workload for community midwives 4 4 16 high insufficient community midwives to manage
workload and shift in care.
Community Midwives to developand
communicate robust clinical pathway.
Devolp robust clinical pathways. Ensure new
ways of working and appropriate new roles and
clinical support. Develop rotation posts and
develop new JDs to support process
2 2 4 low
4 2 8 medium
3k risk of complications in labour during transfer 4 3 12 high 3 3 9 medium
3l
3m
women may arrive at MLU without being
planned and require transfer to City
Women may be inappropriately booked for
MLU
2 3 6 medium women lack understanding of fstand alne
facility and expect full delivery suite to be
available. Increases transfers with adverse
clinical outcomes
Community Midwives to develop and
communicate robust clinical pathway. Wide
promotion and communication of facilities and
function of the unit. Ongoing robust assessment
of individual women, and competency of staff.
4 2 8 medium High risk women ae planned for mlu Devolp robust clinical pathways. Robust
inclusion and exclusion criteria
2 1 3 low
4 1 4 low
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Risk Register