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Found 838 results
  1. News Article
    An investigation has been launched after a woman died during childbirth at a hospital's maternity unit. It was the third death of a mother in just over three years at Basildon University Hospital in Essex, in addition to a newborn baby's death. The trust that runs the hospital said it could not comment on the case while it was under investigation. Basildon University Hospital is part of Mid and South Essex NHS Foundation Trust, which also runs Southend and Broomfield hospitals. The latest fatality follows the death of 36-year-old Gabriela Pintilie in February 2019. Ms Pintilie died after losing six litres of blood giving birth to her second child at the unit. In separate incidents, a mother died and another woman had a stillborn baby at the unit in March 2019, while the trust was being inspected by the Care Quality Commission (CQC) following Ms Pintilie's death. The unit at Basildon had its rating upgraded from "inadequate" to "requires improvement" in December by the CQC. The hospital also apologised for the death of newborn Frederick Terry after he suffered a brain haemorrhage during a failed forceps delivery in November 2019. Read full story Source: BBC News, 27 March 2022
  2. News Article
    When Debbie Greenaway was told by doctors that she should try to deliver her twin babies naturally, she was nervous. But the doctor was adamant, she recalls. “He said: ‘We’ve got the lowest caesarean rates in the country and we are proud of it and we plan to keep it that way'." For Greenaway, labour was seemingly endless. She was given repeated doses of syntocinon, a drug used to bring on contractions. By the second day, the midwife was worried for one of the babies, whom the couple had named John. “She was getting really concerned that they couldn’t find John’s heartbeat.” Her husband remembers “the midwife shaking her head”. “She said a number of times that we should be having a caesarean.” By the time doctors finally decided to perform an emergency C-section, it was too late. Starved of oxygen, baby John had suffered a catastrophic brain injury. When he was delivered at 3am, he had no pulse. Efforts to resuscitate him failed. Their son’s death was part of what is now recognised as the largest maternity scandal in NHS history. The five-year investigation will reveal that the experiences of 1,500 families at Shrewsbury and Telford Hospital Trust between 2000 and 2019 were examined. At least 12 mothers died while giving birth, and some families lost more than one child in separate incidents, the report is expected to show. The expert midwife Donna Ockenden and a team of more than 90 midwives and doctors will deliver a damning verdict on the Shrewsbury trust, its culture and leadership — and failure to learn from mistakes or listen to families. At its heart is how a toxic obsession with “normal birth” — fuelled by targets and pressure from the NHS to reduce caesarean rates — became so pervasive that life-or-death decisions on the maternity ward became dangerously distorted for nearly two decades. Read full story (paywalled) Source: The Times, 26 March 2022
  3. News Article
    A whistleblower who worked at a hospital trust where hundreds of babies died or were left brain-damaged says there was "a climate of fear" among staff who tried to report concerns. Bernie Bentick was a consultant obstetrician at the Shrewsbury and Telford NHS Trust for almost 30 years. "In Shrewsbury and Telford there was a climate of fear where staff felt unable to speak up because of risk of victimisation," Mr Bentick said. "Clearly, when a baby or a mother dies, it's extremely traumatic for everybody concerned. "Sadly, the mechanisms for trying to prevent recurrence weren't sufficient for a number of factors. "Resources and the institutionalised bullying and blame culture was a large part of that." More than 1,800 cases of potentially avoidable harm have been reviewed by the inquiry. Most occurred between 2000 and 2019. Mr Bentick worked at the Trust until 2020. He said from 2009 onwards, he was raising concerns with managers. "I believe there were significant issues which promoted risk because of principally understaffing and the culture," he said. He also accuses hospital bosses of prioritising activity - the number of patients seen and procedures performed - over patient safety. "I believe that the senior management were mostly concerned with activity rather than safety - and until safety is on a par with clinical activity, I don’t see how the situation is going to be resolved," he said. Read full story Source: Sky News, 27 March 2022
  4. Event
    This conference, chaired by Simon Hammond Director of Claims Management NHS Resolution will update clinicians and managers on Clinical Negligence with a particular focus on current issues and the Covid-19 pandemic and the impact on clinical negligence claims. Featuring leading legal experts, and experienced clinicians the event will provide an update on current claims the conference will discuss why patients litigate, and responding to claims including claims regarding Covid-19. There will be an extended masterclass on trends in clinical negligence claims and responding to claims followed by an extended focus on maternity claims, and also claims related to medication error. The conference will close with a case study on the advantages of bringing together complaints, claims and patients safety investigation, and practical experiences of Coronavirus complaints at claims at an NHS Trust – including understanding the standard of care on which services should be judged, and a final session on supporting clinicians when a claim is made against them. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/clinical-negligence or email nicki@hc-uk.org.uk We are delighted to offer 3 free places for hub members. Email info@pslhub.org for the discount code. Follow on Twitter @HCUK_Clare #clinicalnegligence
  5. Content Article
    In Sierra Leone, 34% of pregnancies and 40% of maternal deaths are amongst teenagers and risks are known to be higher for younger teenagers. This qualitative study in Reproductive Health aimed to explore the causes of this high incidence of maternal death for younger teenagers, and to identify possible interventions to improve outcomes. Through focus groups and semi-structured interviews, the authors identified transactional sex - including sex for school fees, sex with teachers for grades and sex for food and clothes - as the main cause of high pregnancy rates for this group. They also identified gendered social norms for sexual behaviour, lack of access to contraception and the fact that abortion is illegal in Sierra Leone as factors meaning that teenage girls are more likely to become pregnant. Key factors affecting vulnerability to death once pregnant included abandonment, delayed care seeking and being cared for by a non-parental adult. Their findings challenge the idea that adolescent girls have the necessary agency to make straightforward choices about their sexual behaviour and contraceptives. They identify a mentoring scheme for the most vulnerable pregnant girls and a locally managed blood donation register as potential interventions to deal with the high rate of maternal death amongst teenage girls.
  6. Content Article
    Research on maternity care often focuses on factors that prevent good communication and collaboration and rarely includes important stakeholders – parents – as co-researchers. To understand how professionals and parents in Dutch maternity care accomplish constructive communication and collaboration, Korstjens et al. examined their interactions in the clinic, looking for “good practice”.
  7. Content Article
    This month an inquiry will deliver its verdict on the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust, the largest maternity scandal in NHS history, involving 1,862 families. The result of this inquiry will highlight how we may need to reconfigure maternity services to ensure the highest standard of care.  But what does good really look like? Is there really a way to be a safe maternity unit?  At last year's Patient Safety Congress, one of the sessions aimed to answer these questions. The panel discussed behaviours and practices that constitute safe care in hospital-based maternity units, and how organisations can take practical steps to make these features a reality. Click on the video below to watch the full session.
  8. News Article
    Women and NHS staff have warned that mothers are being “forgotten” after giving birth, with a staff crisis only making matters worse. Kate, a 32-year-old from Leeds, says she has been left in “excruciating” pain for nine years after horrifying postnatal care. Other women have told The Independent stories of care ranging from “disjointed” to “disastrous”. It comes as midwives warn there are “horrendous” shortages in community services, which have prevented women from accessing adequate antenatal and postnatal care. Mary Ross-Davie, the Royal College of Midwives’ director for professional midwifery, said that with each Covid wave midwifery staffing has been hit worse than the last. To provide safe care during labour, antenatal and postnatal care, teams are sent into wards putting “huge pressure on care”. She said this could mean clinicians end up “missing things”, such as women struggling emotionally after birth. The warnings over poor antenatal and postnatal care come after experts at the University of Oxford said in November there were “stark” gaps in postnatal care, despite the highest number of deaths being recorded in the postnatal period. Dr Sunita Sharma, lead consultant for postnatal care at Chelsea and Westminster Trust, said that when NHS maternity inpatient staffing overall is in crisis “often the first place staff are moved from is the postnatal ward, which is clinically very appropriate, but it can come at a cost of putting more pressure on postnatal care for other mothers”. Dr Sharma said postnatal teams were doing their best to improve services but need national drivers and funding to sustain improvement. Read full story Source: The Independent, 16 March 2022
  9. Content Article
    Matthews et al. investigated inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk. They found that stillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.
  10. Event
    until
    East Midlands and West Midlands Patient Safety Collaboratives will be hosting a webinar on appreciative inquiry (AI). Hosted by Appreciating People, it will focus on ‘what works’ and the existing strengths and assets of people, team and organisations. The pandemic and current working challenges has shown how resilient and creative the maternity and neonatal workforce has been, so this workshop aims to support you to build upon your current knowledge and experiences. The webinar will share tools to focus on levering and amplifying strengths, and there will be time for reflective conversation with colleagues. AI helps build psychological safety and is extensively used by many NHS trusts who are part of Learning From Excellence. Register for the webinar
  11. Content Article
    Sharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this blog, Sharon reflects on events that have unfolded since the publication of the Independent Medicines and Medical Devices Safety Review 'First Do No Harm' report and the Government's response to it. She examines ongoing failures in the government's response and fulfilment of their policy recommendations. Related reading Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response (Sharon Hartles, August 2021) Primodos: The next steps towards justice (November 2020) Mesh: Denial, half-truths and the harms (March 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy
  12. News Article
    A midwife found guilty of misconduct over the death of a baby six years ago is to be struck off. Claire Roberts was investigated by the Nursing and Midwifery Council (NMC) for failures in the care she gave to Pippa Griffiths - who died a day after being born at home in Myddle, Shropshire. An independent disciplinary panel described the midwife as "a danger to patients and colleagues". Ms Roberts and fellow midwife Joanna Young failed to realise the "urgency" of medical attention needed, following the birth, the panel said. They had failed to carry out a triage assessment, after Pippa's mother called staff for help because she was worried about her daughter's condition. The panel concluded Ms Roberts's fitness to practise was impaired. Inaccurate record-keeping by Ms Roberts represented "serious dishonesty", panel chair David Evans said, adding she had carried it out "in order to protect herself from disciplinary action". Her failures had represented a "significant departure from standards expected by a registered midwife," he added. Her colleague Ms Young, whose case was also heard by the panel, faced strong criticism on Wednesday, but was told she would face no sanction after the hearing concluded she had shown remorse and undergone extra training since 2016. Kayleigh Griffiths said she and her husband welcomed the findings and sanctions. "We're really relieved that one of the midwives has been struck off and actually we're also relieved to find that the other midwife has learnt and feels significant remorse for the event that took place," she said. "We realise people do make mistakes and I think how you deal with those mistakes is really important. "All we do ask is that learning was made from those and I think in one of the instances it did occur and in the other it didn't - so I think the right outcome has been found." Read full story Source: BBC News, 10 March 2022
  13. News Article
    The publication of a report into failures of maternity care at an NHS trust has been delayed again. Senior midwife Donna Ockenden has been investigating hundreds of cases in which mothers and babies may have been harmed at Shrewsbury and Telford Hospital NHS Trust (SaTh). Her report had been due to be published on 22 March after being postponed from December. In a letter to families, Ms Ockenden said that date "can no longer happen". She added it was down to "parliamentary processes" which have to happen before the final report can be published. A written statement to Parliament on Tuesday by patient safety minister Maria Caulfield said the NHS had been working to get indemnity cover. She said it would be to cover any potential legal action following the publication of the report and had been agreed in principle by the Treasury. Ms Ockenden's team has been examining 1,862 cases and it is thought to be the largest ever review of maternity care in the NHS. Her interim report published in December 2020 found some mothers were blamed for their babies' deaths. In her letter about the delay, Ms Ockenden said she and her team were "also very disappointed in the delay" and would be working to agree a new publication date. Read full story Source: BBC News, 9 March 2022
  14. News Article
    Midwife-supported homebirths will not be re-introduced in Guernsey after their suspension due to coronavirus. The committee for health and social care explained it is difficult for a small team to accommodate the births. It said that if the service was reinstated, it may impact deliveries on Loveridge Ward in Princess Elizabeth Hospital. A spokesperson said they were "very sorry" to parents who wanted to give birth at home. The committee said homebirths rely on a demanding on-call commitment from community midwives on top of their contracted hours. To facilitate a birth at home, two of the five midwives are required to be on-call for 24 hours a day, for up to five weeks at a time. Deputy Tina Bury, vice president of the committee for health and social care, said: "The midwifery team is small and it was simply not sustainable or safe in the long-term to provide the kind of on-call cover needed to support homebirths. Read full story Source: BBC News, 5 March 2022
  15. Content Article
    In this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
  16. News Article
    Tens of thousands of new mothers have been left feeling “hopeless” and “isolated” during the pandemic, with the NHS seeing record numbers of referrals to mental health services. Requests for help from new, expectant and bereaved mothers jumped by 40% in 2021 compared with 2019, analysis by The Independent has revealed. NHS data shows mental health referrals hit an all-time high of 23,673 in November last year, with average monthly referrals for the whole of 2021 running 21% higher than the year before, jumping from 17,226 to 21,990. Among those affected when support systems were “suddenly” removed in March 2020 was Leanne, a woman who had her second child just before the pandemic and experienced a mental health crisis. She told The Independent how she had struggled following the first lockdown. “I just thought, Oh God, my recovery is going to stop, how am I going to get better now because I’ve got no support – I’m on my own with it,” she said. “I was [also] anticipating the lockdown … in addition to the nursery closing, and I was getting quite anxious about that, and feeling quite hopeless. The pressure piled on me was enormous, and I had no one who could see me or support me." Dr Rosena Allin-Khan MP, the shadow minister for mental health, said the figures uncovered by The Independent were “extremely concerning” and that pregnant women had been “forgotten about through the pandemic”. The Royal College of Psychiatrists’ lead for perinatal mental health services, Dr Joanne Black, said the NHS pandemic recovery plan had lost sight of women in pregnancy and children under two years old, who have been “disproportionately affected”. Read full story Source: The Independent, 28 February 2022
  17. Content Article
    The RCM Podcast is a podcast by the Royal College of Midwives focusing on the work the RCM is doing with and on behalf of its midwife and maternity support worker members. In this episode, Gemma Murphy talks to midwife Vlora Purchase from Greenwich and Lewisham NHS Trust and safeguarding midwife Wendy Warrington from Pennine Care NHS Foundation, to gain insight into the important work they do. Gemma also catches up with RCM staff who developed a new RCM position statement on supporting women with severe and multiple disadvantage during pregnancy.
  18. Content Article
    This article by the National Institute for Health Research (NIHR) summarises recent evidence about the information and support pregnant women need to make decisions about their maternity care, and any interventions they may need. It discusses the following areas: The importance of continuity of carer and personalised care in maternity services Women need clear information and better access to mental health care Helping women with complicated pregnancies make informed decisions about their care Supporting shared decision-making when there are problems with the baby
  19. News Article
    Pregnancy-related deaths among US mothers climbed higher in the pandemic’s first year, continuing a decades-long trend that disproportionately affects Black people, according to a new government report. Overall in 2020, there were almost 24 deaths per 100,000 births, or 861 deaths total, numbers that reflect mothers dying during pregnancy, childbirth or the year after. The rate was 20 per 100,000 in 2019. Among Black people, there were 55 maternal deaths per 100,000 births, almost triple the rate for white people. The report from the National Center for Health Statistics does not include reasons for the trend and researchers said they have not fully examined how Covid-19, which increases risks for severe illness in pregnancy, might have contributed. The coronavirus could have had an indirect effect. Many people put off medical care early in the pandemic for fear of catching the virus, and virus surges strained the healthcare system, which could have had an impact on pregnancy-related deaths, said Eugene Declercq, a professor and maternal death researcher at Boston University School of Public Health. He called the high rates “terrible news” and noted that the US has continually fared worse in maternal mortality than many other developed countries. Reasons for those disparities are not included in the data, but experts have blamed many factors including differences in rates of underlying health conditions, poor access to quality healthcare and structural racism. Read full story Source: The Guardian, 23 February 2022
  20. Content Article
    This report presents maternal mortality rates in the USA for 2020 based on data from the National Vital Statistics System. Maternal mortality rates, which are the number of maternal deaths per 100,000 live births, are shown in this report by age group and race and Hispanic origin. In 2020, 861 women were identified as having died of maternal causes in the United States, compared with 754 in 2019. The maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births compared with a rate of 20.1 in 2019. In 2020, the maternal mortality rate for non-Hispanic Black women was 55.3 deaths per 100,000 live births, 2.9 times the rate for non-Hispanic White women (19.1). Rates for non-Hispanic Black women were significantly higher than rates for non-Hispanic White and Hispanic women. The increases from 2019 to 2020 for non-Hispanic Black and Hispanic women were significant. The observed increase from 2019 to 2020 for non-Hispanic White women was not significant.
  21. Content Article
    This report by Bliss, the UK’s leading charity for babies born premature or sick, found that young parents are often underprepared and under-supported when their babies are in neonatal care. Research by Bliss found that more than half of young parents felt they were not as involved in caregiving or decision-making as they wanted to be when their baby was born premature or sick. It also highlighted contradictory messages that young mothers are given throughout their pregnancy that their youth will be a protective factor, despite an increased risk of prematurity and neonatal mortality for babies born to mothers aged under 20. This myth leaves many young parents feeling unprepared, enhancing their feelings of shock and disbelief if their babies are born unwell.
  22. News Article
    Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC's Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long. Kayleigh Griffiths' baby, Pippa, died at 31 hours old. The cause of death, the couple were later told, was an infection - Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple's input wouldn't be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That's when she decided to send the email to Rhiannon Davies, whose baby, Kate, also died at the Shrewsbury and Telford Hospital NHS Trust As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner's records and death notices to see if any other families had received poor maternity care at the Shropshire trust. They collated 23 cases dating back to 2000 - including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review. One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review. It was outside any national framework that has been used to help learn lessons from incidents and doesn't appear to be a system that's used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons. One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents. The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS - the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades. Read full story Source: BBC News, 23 February 2022 Source:
  23. News Article
    A former consultant gynaecologist has told how he raised concerns over bullying, unsafe practices and a "dysfunctional culture" ahead of a report into a maternity scandal. Bernie Bentick, who worked at Shrewsbury and Telford Hospitals Trust (Sath) for almost 30 years, has spoken publicly about maternity care at the trust for the first time. Sath is at the centre of the largest inquiry in the history of the NHS into maternity care, which is expected to report next month. An official investigation is examining the care that 1,862 families received. Mr Bentick says he told senior management several times about a deteriorating culture at Sath. “I was increasingly concerned about the level of bullying, of dysfunctional culture, of the imposition of changes in clinical practice that many clinicians felt was unsafe," Mr Bentick told BBC's Panorama. "If the resources had been made available to employ adequate numbers, to provide safe levels of care in accordance with national guidelines, then the situation may have been profoundly different.” Mr Bentick went on to say that though some “cursory” investigations were launched into his complaints, he believed the trust responded in a way that tried to “preserve the reputation of the organisation.” Read full story Source: Shropshire Star, 23 February 2022
  24. News Article
    A taskforce has been set up to tackle disparities in maternity care experienced by women belonging to ethnic minorities and those living in deprived areas. Black women are 40% more likely to miscarry than white, studies suggest. Maternal death rates are also higher among black and Asian women. Royal College of Obstetricians and Gynaecologists head Dr Edward Morris told BBC News implicit racial bias was affecting some women's care. Patient Safety and Primary Care Minister Maria Caulfield said: "For too long disparities have persisted which mean women living in deprived areas or from ethnic minority backgrounds are less likely to get the care they need and, worse, lose their child. "We must do better to understand and address the causes of this. "The Maternity Disparities Taskforce will help level-up maternity care across the country, bringing together a wide range of experts to deliver real and ambitious change so we can improve care for all women - and I will be monitoring progress closely." Chief midwifery officer Prof Jacqueline Dunkley-Bent, who will co-chair the taskforce, said: "The NHS's ambition is to be the safest place in the world to be pregnant, give birth and transition into parenthood - all women who use our maternity services should receive the best care possible." The taskforce will meet every two months and focus on: improving personalised care and support plans addressing how wider societal issues affect maternal health improving education and awareness of health when trying to conceive, such as taking supplements and maintaining a healthy weight increasing access to maternity care for all women and developing targeted support for those from the most vulnerable groups empowering women to make evidence-based decisions about their care. Read full story Source: BBC News, 23 February 2022 Source: BBC News,
  25. Content Article
    This is the second in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Marie talks about her campaign for justice for families affected by hormone pregnancy tests, why she is passionate about reforming medicines regulation and the important role patient campaigners play in improving patient safety.
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