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Found 565 results
  1. News Article
    Hackers behind a London hospital attack recently published records that include personal information about pregnant women, newborns, cancer patients, people suffering from schizophrenia and thousands of others across the UK and Ireland, revealing the breach was far more widespread than authorities have previously indicated. An analysis of the data trove by Bloomberg News found that it contains tens of thousands of medical records on patients from more than 400 public and private hospitals and clinics. Among the records are some 40,000 highly sensitive documents sent by doctors requesting biopsies and blood tests for individual patients in all regions of the UK and some hospitals in Ireland. A breach of the kind faced by Synnovis was inevitable, according to Saif Abed, a former NHS doctor and expert in cybersecurity and public health. “The NHS has some of best patient safety and cybersecurity standards in the world,” Abed said. “They are just immensely poorly enforced.” Abed said that there was a lack of mandatory cybersecurity audits on any contractors providing services to the NHS, which meant those contractors could have substandard cybersecurity practices that could in turn leave the NHS vulnerable. Read full story Source: Bloomberg UK, 26 June 2024
  2. News Article
    C2.AI has formally launched its Maternity and Neonatal Observatory at the NHS ConfedExpo in Manchester (Government and Public Sector Journal). The observatory is intended to give hospitals and clinicians a detailed picture of the performance of maternity units and the health trajectories of individual women, so areas of concern can be identified and acted on. The system works by calculating and comparing observed outcomes for women and babies with expected outcomes for these individuals. To do this, it uses AI and machine learning to assess clinical factors, case-mix, and the social determinants of health. Early adopters within the NHS, where maternity services are under intense scrutiny, are expected soon.
  3. Content Article
    Total parenteral nutrition (TPN, also known as PN) is a method of providing nutrition directly into the bloodstream to those unable to absorb nutrients from the food they eat. TPN is used in all age groups, but in babies its use is often as part of a temporary planned programme of nutrition to supplement milk feeds in those too immature to suckle or too sick to receive milk feeds as a result of intestinal conditions. TPN consists of both aqueous and lipid components, which are infused separately into the baby via specific administration sets and infusion pumps. The rate at which TPN is administered to a baby is crucial: if infused too fast there is a risk of fluid overload, potentially leading to coagulopathy, liver damage and impaired pulmonary function as a result of fat overload syndrome. In a recent three and a half year period 10 incidents were identified where infusion of the aqueous and/or lipid component of TPN at the incorrect rate resulted in severe harm to babies through pulmonary collapse, intraventricular haemorrhage or organ damage, and where intensive intervention and treatment were needed. Most of these incidents involved too rapid a rate of infusion.
  4. News Article
    A couple whose child died before birth due to failings in her care hope a new documentary can support their calls for a public inquiry into England's maternity services. Jack and Sarah Hawkins' daughter Harriet was stillborn at Nottingham City Hospital in April 2016. They hope an ITV programme - Maternity: Broken Trust - shown on Sunday evening can help their bid for a wider probe. An independent review into failings in maternity services in Nottingham is now the biggest maternity investigation in NHS history, but a report is not expected to be returned until 2025. Dr and Ms Hawkins - who received a £2.8m settlement over failings in their daughter's care - said a wider investigation was needed to highlight national issues. "I think maternity services across England are absolutely terrible," Ms Hawkins said. "We're in contact with people with dead babies from Leeds to Plymouth, and I think what really needs to happen is for there to be a public inquiry into England's maternity services. "It's not just Nottingham, it's everywhere, and hopefully this platform will give people the strength to come forward and speak up." Read full story Source: BBC News, 10 June 2024
  5. News Article
    Three more babies have died from whooping cough this year as cases continue to rise across the country, according to the UK Health Security Agency. Since January, there have been 4,793 confirmed cases of whooping cough, with 181 babies under the age of three months diagnosed with the illness. A total of eight babies have now died from whooping cough this year. Pregnant women have been urged to get the whooping cough vaccine in order for their babies to be protected before they are old enough to receive the vaccine themselves. Babies can first be vaccinated against the disease when eight weeks old, while pregnant women are advised to get the vaccine at 16 and 32 weeks. Dr Gayatri Amirthalingam, a consultant epidemiologist at UKHSA, said: “Our thoughts and condolences are with those families who have so tragically lost their baby. “With whooping cough case numbers across the country continuing to rise and sadly the further infant deaths in April, we are again reminded how severe the illness can be for very young babies. “Pregnant women should have a whooping cough vaccine in every pregnancy, normally around the time of their mid-pregnancy scan (usually 20 weeks). This passes protection to their baby in the womb so that they are protected from birth in the first months of their life when they are most vulnerable and before they can receive their own vaccines. “The vaccine is crucial for pregnant women, to protect their babies from what can be a devastating illness.” Read full story Source: The Guardian, 6 June 2024
  6. News Article
    A national study is examining whether a treatment for premature babies could cause harm, amid concerns about the deaths of four infants last year, it has emerged. HSJ has learned a national study into the use of prophylactic low-dose hydrocortisone steroids, also known as “premiloc”, is being carried out at the Neonatal Data Analysis Unit, part of the Imperial College London Medical School. Meanwhile, University College London Hospitals Foundation Trust confirmed that four children died in January and February 2023 last year, having been transferred from UCLH to nearby Great Ormond Street Hospital, after receiving the treatment. They had been given hydrocortisone steroids at UCLH to reduce the risk of developing a lung condition called bronchopulmonary dysplasia. UCLH said its own internal investigations “did not confirm a direct link” between the deaths and the drug, “but concern remained” so they were reported to the regional neonatal network. UCLH noted that the national study at Imperial was now under way, although the Imperial team told HSJ it was not specifically aware of the UCLH/GOSH deaths last year. A report from GOSH’s safety team last year, seen by HSJ, said: “In all four deaths the mortality review group identified modifiable/potential modifiable factors around the administration of premiloc prior to admission to GOSH. Administration of premiloc (hydrocortisone steroids) to these babies may have been associated with the subsequent perforations. A series of incidents of perforations was flagged to the UCLH neonatal unit who reviewed data and have stopped the administration of premiloc.” Read full story (paywalled) Source: HSJ, 5 June 2024
  7. News Article
    The families of nine babies who died at a scandal-hit NHS trust over a three-year period have called for a public inquiry into the standard of its maternity care. A collective letter has been sent to each of the families' MPs after they lost babies at hospitals run by the University Hospitals Sussex NHS Foundation Trust. Of the nine bereaved mothers, four said they too almost died as a result of "poor standards of care" from maternity teams between 2021 and 2023 The trust said it had recruited more midwives and "changed" how it supported families, with outcomes now better "than most other trusts in the country". But the Sussex-based families said they had called for a public inquiry into its maternity services to ensure accountability for "systemic failures", and so the trust learns from past mistakes. In the letter to the MPs, the parents said: "With the volume and repetition of errors in maternity care by the trust, we believe that babies and potentially mothers will continue to unnecessarily die under the trust’s care unless there is additional intervention." Read full story Source: BBC News, 4 June 2024
  8. Content Article
    This cohort study in JAMA Network Open aimed to determine whether US Food and Drug Administration (FDA) warnings to prevent prenatal exposure to valproic acid are associated with changes in pregnancy risk and contraceptive use. The study examined 165 772 valproic acid treatment episodes among 69 390 women and found that pregnancy rates during treatment remained unchanged during the 15-year study, and were more than doubled among users with mood disorder or migraine compared with epilepsy. Contraception use among users was uncommon, with only 22.3% of treatment episodes having a 1-day overlap of valproic acid and contraception use. The authors argue that these findings suggest a need to review efforts to prevent prenatal exposure to valproic acid, especially for clinical indications where risk of use during pregnancy outweighs therapeutic benefit and safer alternatives are available.
  9. News Article
    Patients could be put at risk by plans to allow local NHS bodies to oversee the quality of health screening programmes for diseases such as breast and bowel cancer, experts have suggested. At the moment, NHS England runs the Screening Quality Assurance Service (SQAS) to make sure local organisations comply with national standards, are safe and can be subject to inspections. There are 11 national screening programmes in England, including those for breast, cervical and bowel cancer, plus antenatal and newborn screening, abdominal aortic aneurysm and diabetic eye screening. At the moment, screening programmes must report all safety incidents to the SQAS and the SQAS inspectors visit local sites to pick up urgent issues and make recommendations. Now, a report in the British Medical Journal questions plans by NHS England to allow local bodies to have more control. Sue Cohen, former national lead of screening quality assurance at Public Health England, told the BMJ that devolving responsibility for SQAS to local organisations would be a “retrograde” step. She pointed to previous issues, such as in Kent where a lack of oversight of a cervical screening programme led to women with cancer not being picked up. She said: “If you don’t have a quality assurance service that is properly resourced and has that ability to keep a national view, you will simply not have the oversight of the system and there is a bigger risk of incidents going undetected.” Read full story Source: Medscape News, 22 May 2024
  10. Content Article
    The Thirlwall Inquiry is examining events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. As part of this Inquiry, its Terms of Reference asks: “Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?”. To help inform its work in this area, the Inquiry Legal Team has produced this Table of Inquiries and reviews which have been conducted in England and Wales over the last thirty years. Recommendations from each Inquiry have been set out in a comprehensive table, alongside details of whether or not those recommendations have been implemented.
  11. Content Article
    This is the second ‘saving babies’ lives’ progress report from the Joint Policy Unit. When the first report was published in May 2023, the Unit committed to reassessing progress each year. Through this process it aims to hold government and decisionmakers to account, helping to ensure that saving babies’ lives and tackling inequalities in pregnancy and baby loss are the political priorities they deserve to be. This years report highlights that maternity services need a much more transformative approach from government, that matches the scale and impact of the issue. Maternity services are not on course to meet government ambitions to reduce rates of stillbirth, neonatal death or preterm birth, and there continue to be stark and persistent inequalities in rates of pregnancy and baby loss by ethnicity and deprivation. View a summary version of the report
  12. Content Article
    On 9 January 2024, the All-Party Parliamentary Group (APPG) on Birth Trauma established the first national inquiry in the UK Parliament to investigate the reasons for birth trauma and to develop policy recommendations to reduce the rate of birth trauma. Seven oral evidence sessions took place on consecutive Mondays between 5 February and 18 March 2024 in the House of Commons. The Inquiry was also informed by written submissions which were received following a public call for evidence. The inquiry received more than 1,300 submissions from people who had experienced traumatic birth, as well as nearly 100 submissions from maternity professionals. It also held seven evidence sessions, in which it heard testimony from both parents and experts, including maternity professionals and academics.
  13. News Article
    Five babies have died from whooping cough as cases continue to rise in England, health officials have announced. The UK Health Security Agency (UKHSA) reported 1,319 cases in England in March, after just over 900 in February, making the 2024 total nearly 2,800. It fears it could be a bumper year for the bacterial infection. The last peak year, 2016, saw 5,949 cases in England. The infection can be particularly serious for babies and infants. Half of cases seen so far this year have been in the under-15s, with the highest rates in babies under three months of age. The five babies who died this year were all under three months old. Known as pertussis or "100-day cough", the infection is a cyclical disease with peaks seen every three to five years. UKHSA has said a steady decline in uptake of the vaccine in pregnant women and children and the very low numbers seen during the pandemic, as happened with other infections because of restrictions and public behaviour, were both factors. The agency said a peak year was therefore overdue and urged families to come forward to get vaccinated if they had not already. Read full story Source: BBC News, 9 May 2024
  14. Content Article
    This report by the Maternity & Newborn Safety Investigations (MNSI) programme examines findings from 92 of their investigations where safety recommendations were made to midwife-led units in NHS hospital trusts in England. It highlights key learnings and prompts to help trusts to consider how safety risks can be mitigated and drive improvements in care.
  15. News Article
    NHS staff do not correctly monitor a baby’s heart rate during labour in almost half of cases where serious failings lead to tragedy, a review of maternity care has found. The Care Quality Commission identified that inadequate foetal monitoring occurred in 45 of 92 cases (49%) in which a baby died or suffered serious brain damage while being born in a midwife-led unit in England. The findings show that correct monitoring is “critically important” to ensure care is safe in all maternity units, said Sandy Lewis, the director of the CQC’s maternity and newborn safety investigations (MNSI) programme. It analysed four common failings in the 92 births in a report that is intended to help midwives and doctors improve the quality and safety of care. In one case the investigation team found that “there were likely to have been abnormalities in the baby’s heart rate which were ongoing for a prolonged period of time, which were not identified during intermittent auscultation [monitoring]”. In another, midwives were so busy dealing with a separate emergency on the unit that they failed to monitor the baby at the correct recommended intervals and the woman was left unattended. The 92 incidents involved 62 cases in which the newborn suffered a severe brain injury, 19 in which it was alive at the start of labour but was stillborn and 11 when it died within its first six days of life. Read full story Source: Guardian, 8 May 2024
  16. Content Article
    Abbie experienced a high-risk pregnancy with her twin girls. They were born at 27 weeks gestation and weighed in at just 677g and 500g. After 150 nights in Neonatal Intensive Care Unit (NICU), both of Abbie’s daughters came safely home.  In this blog, Abbie highlights the importance of building a trauma-informed, clinical network around women whose babies have spent time in NICU. Drawing on her own experience and insights, she offers suggestions for how midwives, GPs and health visitors can support their mental health postnatally. 
  17. News Article
    Women have been told to avoid using weight-loss drugs to help them get pregnant, as doctors report a rise in surprise “Ozempic babies”. Some women struggling with infertility have unexpectedly become pregnant after being prescribed semaglutide, which is used to treat obesity and type 2 diabetes under the brand names Wegovy and Ozempic. However, scientists have now issued a warning that the weight-loss injections may cause birth defects and should not be used by anyone hoping to become pregnant. Professor Tricia Tan, from the department of metabolism, digestion and reproduction at Imperial College London, said: “Women need to know that these drugs should not be used during pregnancy. You can also see that most of the clinical trials have not included women who are intending to become pregnant. Animal studies did show that the animal babies born to animals who were given these medications had problems.” Read full story (paywalled) Source: The Times, 23 April 2024
  18. News Article
    Lucy Letby is to apply for permission to appeal against her convictions for the murder and attempted murder of babies in her care. A panel of three judges at the Court of Appeal in London is due to consider the former nurse’s case later. The 34-year-old was handed 14 whole life terms last year. She was found guilty of murdering seven babies and attempting to murder a further six at the Countess of Chester Hospital between 2015 and 2016. Second stage Shortly after her trial ended in August, Letby applied for leave to appeal against her convictions. She lost the first stage of the process, in which a single judge reviewed her arguments as a paper exercise. Letby, originally of Hereford, now has the right to a second stage, which involves renewing her application before a panel of judges at a hearing at the Court of Appeal. Separately to the appeal, Letby is due to be re-tried on one charge of attempted murder, which the jury at her trial was unable to decide on. Read full story Source: BBC News, 2 April 2024
  19. News Article
    The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024
  20. Content Article
    Tommy Gillman died on 8 December 2022 from sepsis and multi organ failure secondary to Salmonella Brandenburg meningitis. There were missed opportunities to provide him with earlier antibiotics, fluid resuscitation and intensive monitoring from 12.35pm on the 7 December 2022 at Kings Mill Hospital. Once the severity of his illness had been recognised at approximately 17:00 hours on that day, he was provided with prompt treatment for septic shock and meningitis. Sadly however he did not respond to this treatment and died the following day following transfer to Leicester Royal Infirmary. Whilst there were serious missed opportunities to provide earlier treatment of sepsis and meningitis.
  21. Content Article
    Sands is the UK's leading charity working to save babies' lives and support bereaved families. In this blog, Julia Clark and Mehali Patel from the Sands Saving Babies’ Lives research team, draw on their recent Listening Project to illustrate the value of working with bereaved parents. Julia and Mehali argue that hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care.
  22. News Article
    Black women are up to six times more likely to experience some of the most serious birth complications during hospital delivery across England than their white counterparts, with the figures being described as “stark” and disheartening”, according to analysis. Black women made up 26% of women who experienced the birth complication pre-eclampsia superimposed on chronic hypertension during delivery, despite making up just 5% of all deliveries across England, according to a Guardian analysis of NHS figures for 2022-23. They were six times more likely to experience this pregnancy complication than their white counterparts, who made up 47.2% of these cases despite making up 70% of all deliveries. Read full story Source: Guardian, 8 April 2024
  23. News Article
    Pre-eclampsia affects between 1% and 5% of pregnant women, but more can be done to inform people about its dangers. While pregnant with her son in 2015, Chipiliro Kalebe-Nyamongo’s pregnancy was generally smooth – until she reached about 33 weeks. She started to develop high blood pressure, and was admitted to hospital to be monitored. It was during this period that Kalebe-Nyamongo became concerned when she didn’t feel her baby’s movements as usual. Read full story Source: Guardian, 8 April 2024
  24. News Article
    Families have been told they will have to prove liability for the harm caused to mothers and children at East Kent Hospitals University Foundation Trust before getting compensation. This is despite the inquiry having examined each case in detail and concluding 45 babies could have survived, while 12 who sustained brain damage could have had a different outcome. It also determined 23 women who either died or suffered injuries might have had better outcomes had care been given to “nationally recognised” standards. However, NHS Resolution – which handles claims for clinical negligence – now says families must prove causation and a breach of duty of care before any compensation can be made. This stipulation has been made even in cases where the inquiry found different treatment would have been reasonably expected to make a difference to the outcome. The investigation into the trust’s maternity care led by Bill Kirkup reported 18 months ago. Speaking to HSJ, its author said: “I am disappointed that East Kent families are facing these problems after everything that has happened to them. Of course, it is true that the independent investigation panel was not in a position to rule on negligence, but we did provide a robust clinical assessment of each case. “I would have hoped that this could be taken into account in deciding to offer early settlement instead of a protracted dispute. It seems sad that a more compassionate approach has not been adopted.” Read full story (paywalled) Source: HSJ, 2 April 2024
  25. News Article
    Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss? The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned. “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter. “So Charlotte spent four years in agony,” says James, “thinking it was her.” Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says. Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”. James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them. “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says. Read full story Source: The Guardian, 26 March 2024
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