Safety culture

Developing and sustaining a culture of safety to benefit everyone

The culture of an organisation and the teams within it is shaped by the behaviour of everyone in it. In maternity and neonatal services, a safety culture improves the experience of care for women and babies and supports staff to thrive. Positive cultures exist in many services, and we want everyone to experience a positive culture at work – poor cultures need to be challenged. The failures in care identified in Bill Kirkup’s report on East Kent stemmed from flaws in culture including a lack of teamworking, professionalism, compassion, listening, and learning. The three areas for developing and sustaining a safety culture for everyone are: developing a safety culture, learning and improving, and support and oversight.

Culture is everyone’s responsibility – especially leaders; evidence shows that compassionate, diverse and inclusive leadership is key to enabling cultural change.

Most of the care delivered in maternity and neonatal services leads to good experiences and outcomes. A continuous learning and improvement approach will promote safer care for all.

Our ambition is framed by the Patient Safety Incident Response Framework (PSIRF) which provides a consistent approach across clinical disciplines, including for maternity and neonatal.

While some maternity and neonatal services are supported by their trust to improve and deliver change; others are not. Good oversight is about understanding the issues faced by leaders and helping to resolve them, including intervention before serious problems arise.


Our objectives

  • Develop a positive safety culture: leaders understand ‘how it feels to work here’ so they can make improvements and everyone takes responsibility for safer care.
  • Learning and improving: a compassionate approach to learning from safety incidents.
  • Support and oversight: services receive support before serious problems arise, in line with the Perinatal Quality Surveillance Model. Change is supported by effective system leadership.

Our goals

Description of goal Where are we now? What are we aiming for? When will we get there?
All Provider Trusts take part in the national perinatal culture and leadership programme. 3 out of 8 Provider Trusts have already started on the programme. 100% of Trusts have taken part in the national perinatal culture and leadership programme. 31 October 2024
Improve sharing and learning from near misses, serious incidents and never events. LMNS has variable access to Provider Trust incident data. LMNS has oversight of 100% of Provider Trust incident data so that effective learning can take place. 31 March 2024
Effective implementation of maternity and neonatal PSIRF. Awaiting national maternity guidance (expected on 29 June 2023). NENC event to discuss national guidance planned for 12 July 2023. Standardised approach to implementation of maternity and neonatal PSIRF across the NENC. 31 March 2025

Initiatives we are implementing to help achieve our objectives and goals:

  • Monitor the impact of work to improve culture and provide additional support when needed.
  • Provide opportunities for leaders to come together across organisational boundaries to learn and support each other.
  • Share learning and good practice across all trusts.
  • Oversee implementation of the safety improvement plan.
  • Commission services to support the delivery of safe, equitable and personalised maternity care for the local population.
  • Oversee quality, provide support where improvements are required.
  • Lead local collaborative working to deliver national programme objectives and improve consistency and access to maternity and neonatal services.