Introduction In May 2021, NHS Lothian commissioned an independent investigation by the British Academy of Audiology (BAA) into paediatric audiology services. Their report triggered a national incident identifying systemic failings of paediatric audiology services which led to 155 children being undiagnosed or receiving a delayed diagnosis of hearing loss. This adversely impacted the early years spoken language acquisition thus potentially affecting a number of these children for life. The review also highlighted serious risks to quality in this area due to variable national oversight, no mandatory governance processes and workforce issues. NHS England subsequently recognised the need to investigate issues identified at sites across England and offered recommendations to providers and ICBs.

Aims and objectives of the research project or activity At first glance, only 5 paediatric audiology services in England were flagged for review using the available national diagnostic data. However, it was not until one of the 23 Midlands providers raised concerns, having previously achieved satisfactory grading, that issues emerged. Other paediatric audiology services in the region then began raising concerns through the freedom-to-speak-up route. This service-level intelligence identified potential historic patient harm and on-the-ground services were clearly voicing concerns as to ongoing patient harm.

The main aims and objectives:

1. Patient safety – review historic and avoid further harm

2. Review governance structures and implement a robust framework

3. Review training of staff and workforce issues – including accountability, registration, accreditation and peer-review

4. Implement a long term self-sustainable model including a clear, joined up commissioning of paediatric audiology services

5. Review leadership oversight for the whole of paediatric audiology – from birth to the point of transfer to adult services

Method or approach Keen to avoid failings of the past, such as those highlighted in the Francis and Keogh reports, the Midlands formed an incident management team after an initial situational risk assessment. This was led by the regional chief scientific officer (CSO), patient safety director and head of system improvement and clinical services as well as having regional medical director oversight. It is important to stress the deliberate multidisciplinary nature of the leadership team utilised in this case, as historically patient safety incidents such as these, have had physician ownership. The intricate details and nuanced nature of the paediatric audiology services has required a variety of expertise in handling the response to numerous challenges and mitigation of risks as they arise. A list of measurable criteria to define clinical quality and good governance was developed. Services in the region were then asked to submit relevant data for assessment and grading.

Findings Understandably, providers found this process upsetting given potential patient safety issues within their service. A strict no-blame culture and transparency was adopted during site visits and discussions with services. Furthermore, framing aid as a way services could recover, all the while ensuring patients had ongoing access and identifying problems early, was received positively. Services with no significant concerns identified were deemed to be the highest quality and chosen to support others in a peer-to-peer quality improvement group and provide mutual aid. To educate and engage systems, BAA webinars and audiology quality improvement groups were set up. These enabled Trusts and ICBs to familiarise themselves with the subject matter but also allowed for clinical concerns, questions and feedback to be shared across systems. Clinical reference groups were initiated to bring leaders together to learn and collaborate with stakeholders and thus provide cross-system support. Other regions in the UK have now requested that our learnings from this process are shared with regional CSOs who are currently reviewing their own paediatric audiology services. This ongoing dialogue with other regions has allowed us to gain feedback, so we can continually learn and implement changes if alternative solutions are more effective.

Key messages The process has clearly demonstrated deficiencies in clinical governance structures and leadership oversight within paediatric audiology services, which in turn has perpetuated poor practice. There have been challenges when questioning services with historic practices, but positive impact from the transparent and methodological approach can already be demonstrated. At site visits, providers have described feeling listened to and ‘not feeling alone’. The ‘arm around the shoulder’ approach has been valued during uncertain times. One site explained how they felt empowered due to governance processes now being implemented and have invested in an audit lead as well as training of staff. The Midlands continue to use this flexible and collaborative approach by offering additional support, pastoral care and mentorship to staff. By sharing learnings outside of the region, the Midlands serve as patient safety champions helping others around the country delve into issues within their own services to avoid further patient harm.