National audit of LSA supervisory investigations

The National Independent Local Supervising Authorities in England audit report presents findings from the national audit undertaken across the four regions of NHS England.

The audit period extended from April to September 2016 and involved the audit of midwifery supervisory investigations carried out between 1 January 2014 and 31 December 2015. The first LSA Single Operating Model was published by NHS England in March 2016 (NHS England 2016). This model provides a robust platform for consistent deployment of LSA responsibilities and aims to reduce unwarranted variation. The audit of supervisory investigations took place prior to the publication of the LSA Single Operating Model.

The audit was commissioned by NHS England as a result of a response to a complaint report submitted to NHS England LSA. The complaint related to the quality and comprehensiveness of a supervisory Investigation that was found to be flawed and not ‘fit for purpose’. One of the recommendations outlined in the report was that an audit should be undertaken to provide assurance to LSA England that the weaknesses found in the LSA Investigatory Processes in 2009 are no longer inherent in the current process.

The findings of the audit provide opportunities for wider learning and continued improvement to investigations processes. There are also opportunities for learning to inform the new employer model of supervision, which is likely to be published when the current statutory model ends. This is likely to be early April 2017.

In addition to capturing evidence about compliance with the current supervisory investigation process, this report also aims to be forward-looking in its recommendations.

Following discussions with the parents of Kate Stanton-Davies, NHS England is carrying out a further and more detailed review of a sample of the cases audited. We are grateful to Miss Davies and Mr Stanton for their support for this audit and the ongoing review.


National Audit Report