Since April 2004, a Clinical Midwife has been seconded to the role of Clinical Reviewer to undertake regular audits of compliance with recommendations. Audit results are tabled and discussed with the Douglas Inquiry Audit Committee with actions identified and tracked. In 2007 this committee meets quarterly to continue ongoing monitoring and performance evaluation and to imbed the ongoing program of quality activities into the organisation's operations. These are monitored by the chair of the Quality Improvement Committee.
Between 2002 and 2005 the Department of Health Internal Audit branch completed three audits of the implementation of recommendations and ongoing compliance. The Implementation of the Douglas Inquiry recommendations Review Final Report (April 2005) stated that "there is satisfactory ongoing compliance with the substance of all of the Douglas Inquiry recommendations for which Women's and Children's Health Services, of which KEMH forms part, are responsible".
In February 2004, an independent review of selected clinical cases at KEMH was undertaken by Professor Emeritus Roger J Pepperell and further recommendations made.
In September 2006, an independent expert review occurred. Its aim was to assess the accuracy of the KEMH Audit Committee, in its interpretation of the recommendations from the Douglas Inquiry regarding clinical audit and the audit program at KEMH and to make informed comment on the audit process to date.
Extract taken from Draft Final Report by Independent Reviewers in Sept 2006:
"The committee has ensured a rigour within the audit process seldom seen in the quality arena within healthcare. Not only is there rigour associated with construction of the audit tools, but there is a consistency across the audits which encourages uniformity of analysis, of interpretation and of reporting."