National audit of LSA supervisory investigations

The National Independent Local Supervising Authorities (LSA) 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

External review of a sample of LSA (England) Supervisory Investigations

A review was commissioned by NHS England in response to two previous commissions both of which related to the quality of midwifery supervision. Although statutory supervision has been removed and replaced with a new model of supervision, A-EQUIP, this review still provides a valuable opportunity to highlight areas where the quality of investigations can improve the involvement of service users.

The aims of the review were:

  • To establish whether each case included in this review has had a robust and objective Supervisory Investigation into the standard of midwifery practice and was undertaken in compliance with the relevant LSA process and guidelines.
  • To identify learning points that will inform and promote a strengthened investigatory process into incidents where there are concerns about the standard of midwifery practice.
  • To share the findings and learning points of this review with each of the sample cohort families; the relevant Trust, NHS Improvement and the Healthcare Safety Investigation Branch (HSIB).

The review sample is comprised of NHS maternity cases in England which resulted in poor maternal and/or fetal/neonatal outcome and was subject to a supervisory investigation between the months of April through to December 2016 inclusive.

The rationale for selecting this time period relates to the publication of the LSA single operating model in March 2016, which aimed to ensure a consistent approach to supervisory processes in England.