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Showing results for tags 'Maternity'.
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Content Article
This joint report by the APPG on Baby Loss and the APPG on Maternity is a culmination of over 100 submissions to an open call for evidence from staff, service users and organisations, on the maternity staffing crisis. It paints a picture of a service that is at breaking point and staff that are over-worked, burnt out and stressed.- Posted
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- Workforce management
- Additional staff required
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Content Article
The Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.- Posted
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- Investigation
- Safety culture
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Content Article
A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry.- Posted
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- Leadership
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Event
untilJoin ImproveWell and representatives from Royal Cornwall Hospital NHS Trust and Shrewsbury and Telford Hospital NHS Trust, to discover: how the current landscape in maternity services looks as regards quality, safety, and workforce sentiment; how engaging the workforce to improve is the key to positive transformation; and lessons and best practice in engaging the workforce in improvement within the maternity services at Shrewsbury and Telford Hospital NHS Trust and Royal Cornwall Hospital NHS Trust. Register for this event- Posted
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News Article
NHSE drops tech target
Patient Safety Learning posted a news article in News
NHS England has revealed it is no longer planning to meet a long-term plan maternity digitisation target, because of a change of approach. Under the heading of “empowering people”, the 2019 long-term plan promised to extend digital access to maternity records to the whole country by 2023-24. This was in addition to digitising the so-called red book, which is used to track the health of babies and young children. It followed a recommendation in the 2016 Better Births report, led by former health minister Baroness Julia Cumberlege and commissioned by NHS England. It was intended to reduce bureaucracy and improve safety, as well as provide parents with better information. However, a paper prepared by chief nursing officer Ruth May for NHSE’s October board meeting said while the organisation “remains committed” to digitising the records, meeting the 2024 deadline would be a challenge due to “varying levels of digital maturity and change capacity across maternity services”. In response, Royal College of Obstetricians and Gynaecologists president Edward Morris told HSJ: “While we recognise the enormous pressures that maternity services are currently facing, we are disappointed that NHSE is no longer on track to meet the target to digitise maternity records by 2024. “This programme of digitisation will help realise our ambition for more effective use of data collected during pregnancy, to help identify and prevent the future onset of disease and improve outcomes for women and their babies. “If digital maternity records are to become part of the wider shift to electronic patient records, it is vital that this information is still accessible to both women and healthcare professionals as an important tool for shared decision making.” Read full story (paywalled) Source: HSJ, 11 October 2022- Posted
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- Technology
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Content Article
AvMA case study: Lyndsey's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control.- Posted
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Content Article
This article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive. -
Content Article
This article tells the story of Baby E, who died two hours after delivery following issues with the management of her labour. The maternity unit was short-staffed on the night of Baby E's birth and there were delays in getting her mother to theatre for a caesarean section. Baby E's parents felt that the hospital withheld information from them, failing to inform them of internal investigations that had taken place following Baby E's death. At the inquest, the coroner concluded that errors had been made, including the fact that Baby E's low heart rate had been missed. She also criticised the decision-making process in the management of labour, but concluded that she was unable to say whether this had made a difference to whether or not Baby E lived. -
News Article
Hospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022- Posted
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- Transparency
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Content Article
This blog by Victoria Vallance, Director of Secondary and Specialist Care at the Care Quality Commission (CQC) discusses how engagement with frontline NHS maternity staff has informed the CQC's inspection approach, and is being used to support improvements in care. She highlights that recent reviews and reports highlight recurring concerns that affect maternity safety: the quality of staff training, poor working relationships between obstetric and midwifery teams, and a lack of robust risk assessment. She then goes on to talk about an event held by the CQC that brought together staff from NHS maternity services across England to discuss the challenges that they face and seek their views on what needs to change to overcome them.- Posted
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- Maternity
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Content Article
Top tips: Maternal mental health (26 September 2022)
Patient Safety Learning posted an article in Maternity
As part of maternal mental health awareness week, The Motherhood Group asked Sandra Igwe for her tips to look after your mental health and wellbeing.- Posted
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- Maternity
- Womens health
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Content Article
The Mental Health Foundation proudly support Black Maternal Mental Health Week in this blog for The Motherhood Group on the experiences of Black mothers.- Posted
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- Mental health
- Maternity
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Content Article
In general approximately 1 in 5 women from all different backgrounds experience perinatal mental health difficulties – that is mental health challenges during the perinatal period which is defined as one year after the birth of a baby. However, for black women perinatal mental health difficulties often go unidentified, and thus untreated, placing them at a disadvantage when it comes to seeking professional help. For this year's Black Maternal Mental Health Week, Global Black Maternal Health is proud to support The Motherhood Group as they continue to raise awareness on black maternal mental health, with a focus on equity and inequality for black mothers.- Posted
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- Mental health
- Maternity
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Content Article
An open letter to Brandon Lewis, the justice secretary, and the Sentencing Council for England and Wales warns that pregnant women in jail suffer severe stress and highlights evidence suggesting they are more likely to have a stillbirth. The signatories include the Royal College of Midwives and Liberty. -
Content Article
In this article for The Guardian, journalist Sirin Kale speaks to Janet Williams about the impact the epilepsy drug sodium valproate has had on her family. Janet took the medication to treat her epilepsy throughout her two pregnancies in 1989 and 1991, but had never been warned about the potential risks to her babies. Foetal valproate syndrome can cause spina bifida, congenital heart defects and developmental delays and is believed to have affected around 20,000 children in the UK. Both of Janet's sons were affected by the medication and require full time care as a result. Janet describes how being told about the risks would have enabled her to make an informed decision about whether to have children, and how her experience led her to help set up In-FACT (the Independent Fetal Anti Convulsant Trust) in 2012.- Posted
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News Article
Staffing shortages force NHSE to abandon safety target
Patient Safety Learning posted a news article in News
NHS England has this week told trusts it is abandoning a patient safety target ‘until maternity services in England can demonstrate sufficient staffing levels’ to meet it. The Midwifery Continuity of Care model was designed to ensure expectant mothers would be cared for by the same small team of midwives throughout their pregnancy, labour and postnatal care. It was a key recommendation of 2016’s Better Births review of English midwifery services. NHSE’s chief midwifery officer for England Jacqueline Dunkley-Bent championed the policy and guidance on its implementation was issued in October. However, in her report on the care failures at Shrewsbury and Telford Hospital Trust’s maternity department, Donna Ockenden said the Midwifery Continuity of Care model should be suspended until more evidence was gathered about its effectiveness and there were enough midwives to meet minimum staffing requirements. Ms Ockenden said patient safety had been “compromised by the unprecedented pressures that Continuity of Care models of care place on maternity services already under significant strain”. Read full story (paywalled) Source: HSJ, 23 September 2022- Posted
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- Lack of resources
- Maternity
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Content Article
Patient Safety Now: safety II and maternity (September 2022)
Patient-Safety-Learning posted an article in Maternity
Safety II moves away from simply looking at what went wrong, and aims to understand the realities of everyday work in a constructive and positive way. It focuses on the system as a whole, rather than the end result of the work done. In this blog, Professor Suzette Woodward, Professional and Clinical Advisor in Patient Safety, looks at the role of the Safety II approach in making maternity services safer. She outlines the importance of asking and listening to staff about how to reduce complexity and reform areas of the system that are prone to error. -
Content Article
This guide is designed to support healthcare providers when talking to patients about the use of of oxytocin to start or advance labour. -
News Article
Many English maternity units not meeting safety standards
Patient Safety Learning posted a news article in News
More than half of maternity units in England fail consistently to meet safety standards, BBC analysis of official statistics shows. Health regulator the Care Quality Commission (CQC) rates 7% of units as posing a high risk of avoidable harm. A further 48% require improvement. The figures are slightly worse than a few years ago, despite several attempts to transform maternity care. The regulator says the pace of improvement has been disappointing. In most cases, pregnancy and birth are a positive and safe experience for women and their families, says the CQC. But when things do go wrong, it is important to understand what happened and whether the outcome could have been different. Laura Ellis lost her newborn son when he was unexpectedly breech during advanced labour. She checked out the CQC rating of her local hospital, Frimley Park, when she was pregnant. Maternity services were good. But Laura didn't realise the unit had been told that it required improvement on safety. Laura said: "It was just so hard. So hard to deal with. So hard to leave as well. How would you leave your baby in hospital when you should be taking them home?" Frimley Park NHS Foundation Trust says it has made a number of changes since Theo died, including an emergency response if a baby is unexpectedly breech during advanced labour. Read full story Source: BBC News, 21 September 2022 -
Content Article
Are you applying Safety-II principles to improve safety in maternity, A&E, ICU or anaesthetics? If so, Dr Ruth Baxter would love to interview you! -
Content Article
Midwives, public health nurses and practice nurses are in an ideal position to address mental health and emotional well-being with women in the perinatal period. However, research involving midwives, public health nurses and practice nurses in Ireland indicates that there is considerable variation in perinatal mental health assessment and care. All three groups identify the following issues as barriers to addressing perinatal mental health issues: Lack of knowledge on the range of perinatal mental health problems Lack of skill in opening a discussion and developing a plan of care with women Organisational issues, such as lack of policies, guidelines and care pathways This document produced by the Irish Health Service Executive, aims to provide an evidence-based guidance document for midwives, public health nurses and practice nurses in the area of perinatal mental health care.- Posted
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- Ireland
- Mental health
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News Article
Staff warned of ‘harrowing’ care standards review
Patient Safety Learning posted a news article in News
Trust staff have been warned that an independent investigation into maternity services will be ‘a harrowing read’ with a ‘profound and significant impact’. The report into services at East Kent Hospitals University Foundation Trust between 2009 and 2020 had been expected to be published on Wednesday 21 September. However, this morning families involved in the investigation received an email saying publication would be postponed to an unknown date in October.. Next Wednesday, when the report was expected to be released and a statement made to Parliament, has been set aside for all MPs to take an oath of allegiance to King Charles III. An email sent to staff at East Kent last week and seen by HSJ said publication would place “significant focus on the trust and all of our services”, and that the trust would make support available to staff as well as former, current and potential patients. The trust will not see the report before publication. The investigation – led by Dr Bill Kirkup, who also led the Morecambe Bay maternity investigation – was prompted by the death of week-old Harry Richford after a traumatic birth at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Around 200 families are thought to have contacted the investigation team with concerns around maternity care. Read full story (paywalled) Source: HSJ, 15 September 2022- Posted
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News Article
Nottingham review scope 'wider than UK's biggest maternity scandal'
Patient Safety Learning posted a news article in News
The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022- Posted
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- Investigation
- Maternity
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Content Article
Unsafe maternity care has cost the National Health Service in England (NHS) £8.2bn in 15 years. How many more surveys of women’s experiences, reports of poor quality care and failings of senior management at NHS maternity units do we need to know that there is still a massive problem with maternity services in England? Judy Shakespeare, Elizabeth Duff and Debra Bick discuss why a joined-up policy and investment in maternity services is urgently needed. -
Content Article
This document outlines the terms of reference for the independent review into maternity services at Nottingham University Hospitals NHS Trust (NUH), commissioned by NHS England and led by Donna Ockenden. The review has been established in light of significant concerns raised about the quality and safety of maternity services at NUH, and concerns voiced by local families. It replaces a previous regionally-led review after some families expressed concerns and made representations to the Secretary of State for Health and Social Care. The review began on 1 September 2022 following early engagement with families and NUH from June 2022. It is expected to last 18 months, although this timeframe is subject to review. Learning and recommendations will be shared with NUH as they become apparent, to allow rapid action to improve the safety of maternity care. The only and final report is expected to be published and presented to NUH and NHS England around March 2024.- Posted
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- Maternity
- Investigation
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