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EventuntilThis Patient Information Forum webinar will share the key findings of our survey on maternity decisions. Our expert panel will share recommendations to help empower women to make informed decisions about the induction of labour. Open to members and non-members. Register
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News ArticleA hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021
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Content ArticleObstetric incidents can be catastrophic and life-changing, with related claims representing the Clinical Negligence Scheme for Trusts’ (CNST) biggest area of spend. The Maternity Safety Strategy set out the Department of Health and Social Care’s ambition to reward those who have taken action to improve maternity safety supported through the Maternity Incentive Scheme. Year four of the Maternity Incentive Scheme launched on 9 August 2021. The scheme supports the delivery of safer maternity care through an incentive element to trust contributions to the CNST. The scheme, developed in partnership with the national maternity safety champions, Dr Matthew Jolly and Professor Jacqueline Dunkley-Bent OBE, rewards trusts that meet ten safety actions designed to improve the delivery of best practice in maternity and neonatal services. In the fourth year, the scheme will further incentivise the ten maternity safety actions from the previous year with some further refinement.
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News Article
Stillborn baby's parents receive £2.8m from Nottingham hospital trust
Patient Safety Learning posted a news article in News
A couple whose child died in the womb after mistakes by maternity staff have received a £2.8m settlement. Sarah Hawkins was in labour for six days before Harriet was stillborn at Nottingham City Hospital in April 2016. Hospital bosses initially found "no obvious fault", but an external inquiry identified 13 failings in care. Solicitors representing Mrs Hawkins and husband Jack said it was believed to be the largest payout for a stillbirth clinical negligence case. Mrs Hawkins was nearly 41 weeks' pregnant when Harriet was delivered, almost nine hours after dying. The couple were first told their child had died of an infection but refused to accept this and launched their own investigation. A Root Cause Analysis Investigation Report published in 2018 concluded the death was "almost certainly preventable". The report said errors included a delay in applying appropriate foetal monitoring, the important omission of information on an antenatal advice sheet and a failure to follow the Risk Management Policy for maternity. It also found failures to record or pass on information correctly, failure to follow correct guidelines and delays in administering the correct treatment. Following the report's publication, the hospital trust apologised and said major changes would be made. Read full story Source: BBC News, 6 December 2021 -
Content ArticleThis training documentary by the South East Perinatal Mental Health team explores race inequalities within the NHS maternity system. It uncovers the stories behind the MBRRACE report figures and looks for answers from leading race and diversity health professionals and campaigners. In the film, midwives and mothers talk frankly about the issues and how individuals can make a difference to create a positive impact on race inequality outcomes for mothers and within maternity teams.
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News Article
Mid and South Essex NHS Foundation Trust told it must improve
Patient Safety Learning posted a news article in News
Changes must be made across services at one of England's biggest NHS trusts following its first wide-ranging inspection, a health watchdog said. Mid and South Essex NHS Foundation Trust - which runs Basildon, Southend and Broomfield hospitals - has been rated as "requires improvement". The Care Quality Commission (CQC) turned up unannounced after concerns over standards were raised. Philippa Styles, the CQC's head of hospital inspection, said they "found a mixed picture" of positive improvements and areas of concern. "Following the trust's formation in 2020, leaders should now be able to work together effectively to ensure care is consistent across all services," she said. "I recognise the enormous pressure NHS services are under... and that usual expectations cannot always be maintained, especially in the urgent and emergency department, but it is important they do all they can to mitigate risks to patient safety." The report said: Patients had not always been protected from harm. Staff had not all received mandatory training. There had been nine "never-should-happen" medical events. Records were sometimes inaccurate and not kept securely. Nursing and medical staffing was a "challenge across the trust", with shifts regularly below planned staffing numbers. There had been a high number of whistle-blowers raising concerns. Read full story Source: BBC News, 1 December 2021 -
Content ArticleWhere a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
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Content ArticleAt the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable. Suzanne White, a former radiographer and a clinical negligence lawyer for the past 25 years, looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
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EventThis webinar will feature two presentations on: Lancet article - Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study NMPA report - Ethnic and socio-economic inequalities in NHS maternity and perinatal care for women and their babies There will be a Q&A guest panel featuring: Professor Eddie Morris Clo and Tinuke, Five X more Bell Ribeiro-Addy MP Professor Jacqui Dunkley-Bent Professor Marian Knight Professor Asma Khalil Join the webinar on Microsoft Teams
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Content Article
Birthrights video: Speak Up, Speak Out (16 November 2021)
Patient-Safety-Learning posted an article in Maternity
This video by the charity Birthrights encourages women and birthing people to speak out when they experience poor quality care. It highlights the right to safe and appropriate maternity care that respects individuals' dignity, privacy and confidentiality and is given equally and without discrimination. -
News ArticleThe increased risk of black and minority ethnic women dying during pregnancy needs to be seen as a whole system problem and not limited to just maternity departments, according to experts on an exclusive panel hosted by The Independent. Professor Marian Knight, from Oxford University told the virtual event on Wednesday night that the health service needed to change its approach to caring for ethnic minority women in a wider context. Campaigners Tinuke Awe and Clotilde Rebecca Abe, from the Fivexmore campaign, called for changes to the way midwives were trained and demanded it was time to “decolonise the curriculum” so it recognised the physiological differences between some ethnic minority women and white women. Dr Mary Ross-Davie, from the Royal College of Midwives, said work was underway to ensure the voices of black women and other minorities were represented in its work and it was examining how it could deliver better training to midwives. The data on maternity deaths in the UK show black women are four times more likely to die during pregnancy in the UK than white women. For Asian women, they are twice as likely to die. Read full story and watch video of event Source: The Independent, 18 November 2021
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News Article
'Some progress' made at failing Shropshire hospital trust
Patient Safety Learning posted a news article in News
An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate. The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths. The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards. Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent" and and urgent and emergency care where patients "did not always receive timely assessment". The CQC also reported a shortage of staff working in end-of-life care and midwifery, however maternity staff were said to have "an exceptionally dedicated and caring approach". "I recognise the enormous pressure NHS services are under across the country and that usual expectations cannot always be maintained, but it is important they do all they can to mitigate risks to patient safety while facing these pressures," chief inspector of hospitals, Ted Baker, said. "While the trust continues to have significant work to do to provide care that meets standards people have a right to expect, it is providing more effective care overall. "However, its risk management remains inconsistent and we are not assured it is doing all it can to ensure people's safety." Read full story Source: BBC News, 18 November 2021 -
Content Article
National Maternity and Perinatal Audit lay summaries (2021)
Patient-Safety-Learning posted an article in Maternity
The National Maternity and Perinatal Audit (NMPA) has produced lay summaries covering three of its sprint audits into: perinatal mental health services maternity care for women with a body mass index of 30kg/m2 or above ethnic and socio-economic inequalities in NHS maternity care. The NMPA is a large-scale project established to provide data and information to those working in and using maternity services. The purpose of NMPA is to evaluate and improve NHS maternity services, as well as to support women, birthing people and their families to use the data in their decision-making. -
Content ArticleIn this study in BMC Pregnancy and Childbirth, the authors examined the views of men from Uganda currently living in the UK of an educational board game used to promote engagement in maternal health. Men can play a significant role in reducing maternal morbidity and mortality in low-income countries and maternal health programmes are increasingly looking for innovative interventions to engage men to help improve health outcomes for pregnant women. The study found that men were receptive to the board game and reported that easy-to-understand visual aids and messages helped change their perspective. Participants suggested that the game needs to be adapted to the local context for use with men in rural Uganda.
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Content ArticleThis report from the National Maternity and Perinatal Audit assesses care inequalities using data from births between 1 April 2015 and 31 March 2018 across England, Scotland and Wales. The National Maternity and Perinatal Audit (NMPA) is led by the Royal College of Obstetricians and Gynaecologists (RCOG) in partnership with the Royal College of Midwives (RCM), the Royal College of Paediatrics and Child Health (RCPCH) and the London School of Hygiene and Tropical Medicine (LSHTM).
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Content ArticleThis report, the eighth MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2017 and 2019 in the UK. In addition, it also includes Confidential Enquiries into the care of women who died between 2017 and 2019 in the UK and Ireland from mental health-related causes, venous thromboembolism, homicide and malignancy. The report also includes a Morbidity Confidential Enquiry into the care of women who gave birth aged over 45 years. This report can be read as a single document; each chapter is also designed to be read as a standalone report as, although the whole report is relevant to maternity staff, service providers and policy-makers, there are specific clinicians and service providers for whom only single chapters are pertinent. There are seven different chapters which may be read independently, the topics covered are: 1. Surveillance of maternal deaths 2. Older maternal age (morbidity enquiry) 3. Mental health and multiple adversity 4. Malignancy 5. Venous thromboembolism.
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News Article
‘Outstanding’ rated trust given CQC warning notice after staff raised alarm
Patient Safety Learning posted a news article in News
An acute trust currently rated ‘outstanding’ has been served with a warning notice by the Care Quality Commission, after senior doctors’ safety concerns prompted an inspection. Inspectors visited University Hospitals Sussex Foundation Trust days after HSJ reported on a letter from consultants highlighting “an extremely unsafe situation” and calling for elective work to be moved away from one of the trust’s main hospitals. The inspection looked at surgical areas at the Royal Sussex County Hospital, in Brighton, and maternity services at four sites – the RSCH, St Richard’s in Chichester, Worthing Hospital and the Princess Royal Hospital in Haywards Heath. In a letter to all staff, seen by HSJ, chief executive Dame Marianne Griffiths said the trust was “striving to improve” but that “the last four months are like nothing I have ever seen before. Like others we are facing unprecedented daily challenges”. She said: “High patient numbers combined with continuing to work through the pandemic with the stringent infection prevention and control processes that entails make for a challenging work environment.” Chief nurse Maggie Davies said: “The safety of our patients is always our number one priority. Our services remain under unprecedented pressure and our staff are working hard to provide the highest standards of care to all our patients. Read full story (paywalled) Source: HSJ, 5 November 2021 -
News ArticleSocioeconomic inequalities account for an estimated quarter of stillbirths, fifth of preterm births, and a third of births with fetal growth restriction, according to a study published in the Lancet of over one million births in England The nationwide study across England’s NHS was carried out by the National Maternity and Perinatal Audit team, who analysed birth records between April 2015 and March 2017 to quantify socioeconomic and ethnic inequalities in pregnancy outcomes. They found that an estimated two thirds (63.7%) of stillbirths and half (55.0%) of births with fetal growth restriction in black women from the most deprived neighbourhoods could be avoided if this population had the same risks as white women living in the most affluent 20% of neighbourhoods. Read full story (paywalled) Source: BMJ, 2 November 2021
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Content ArticleThis nationwide study of over 1 million births in the English NHS between 2015 and 2017, published in The Lancet, has found large inequalities in pregnancy outcomes between ethnic and socioeconomic groups in England. The findings from Jardine et al. suggest that current national programmes to make pregnancy safer, which focus on individual women's risk and behaviour and their antenatal care, will not be enough to improve outcomes for babies born in England. The authors say that to reduce disparities in birth outcomes at a national level, politicians, public health professionals, and healthcare providers must work together to address racism and discrimination and improve women's social circumstances, social support, and health throughout their lives.
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EventHave you been invited to participate in an HSIB maternity investigation? Are you unsure of what the programme is about? Do you have questions about HSIB maternity investigations? This webinar is primarily aimed at doctors in training but will be of interest to clinicians from any professional background and especially to those working within maternity and neonatal services. You will gain a high level overview of the programme, an understanding of our system approach to healthcare safety investigations and information about our investigation methodology. There will be a panel discussion at the end where you will have the opportunity to have any outstanding questions answered. Register
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News ArticleA freedom of information request by HSJ has for the first time revealed a complete list of participants in NHS England’s maternity safety support programme, with 28 trusts involved since its inception in 2018. London North West University Healthcare Trust, Northern Lincolnshire and Goole Foundation Trust, and Worcestershire Acute Hospitals Trust all entered the scheme at the start, due to pre-existing quality and safety concerns. The trusts were all subsequently removed, having been deemed to have made improvements, but have since been placed back in it following inspections by the Care Quality Commission (see table below). HSJ asked the trusts to explain why they had re-entered the scheme, and why it had failed to deliver sustainable improvements the first time, but they declined to comment. NHSE said in a statement: “Trusts are placed on the maternity safety support programme according to complex criteria, including local insight and external performance measures, including CQC ratings. “Following the success of the programme since its creation in 2018, its criteria was widened to strengthen its role in proactively improving safety and enabling earlier intervention where there are concerns — this has allowed support to be offered to more trusts than in previous years.” However, it would not provide further details on the new entry criteria. Three further trusts — Barts Health, North Devon Healthcare, and the Queen Elizabeth Hospital King’s Lynn — have previously exited the programme and not so far re-entered. Trusts such as Shrewsbury and Telford and East Kent — which have been at the centre of major maternity scandals — have been on the improvement scheme for all four years. Peter Walsh, chief executive of the patient safety charity Action against Medical Accidents, said: “The number of NHS maternity services being found to be needing improvement is worrying. We welcome the fact that NHS England is devoting resources to support trusts to improve their maternity services, but there should be much more transparency about this. “The criteria for needing this support should be published, and indeed should have been subject to consultation.” Helen Hughes, chief executive of patient safety charity Patient Safety Learning, said there should be transparency about resource allocation and the criteria used to make decisions, adding: “It doesn’t appear that this information is easily accessible and in the public domain and rather begs the question, why not?” NHSE said trusts receiving support from the programme detail this in their board papers, although HSJ found this is not always the case. It added trusts are made aware of the rationale for inclusion on an individual basis. NHSE and the Department of Health and Social Care last year described the maternity safety support programme as the “highest level of maternity-specific response”. They have said the programme “involves senior clinical leaders providing hands on support to provider trusts, through visits, mentoring, and leadership development”. Full article here (paywalled) Original source: Health Service Journal
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Content ArticlePoppy Harris was born at Milton Keynes University hospital on 23 November 2020. Following a protracted labour, she was delivered using Kielland's forceps. She was transferred to John Radcliffe Hospital in Oxford where it was discovered that she had suffered a spinal cord injury and despite all efforts and care she died on 24 March 2021.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on the 21st October 2021, which notes disappointment with the UK Government’s response to the Independent Medicines and Medical Devices Safety Review. The motion calls on the Government to reconsider its response and to implement all nine recommendations in their entirety, and to ensure patient safety remains paramount in any changes to regulatory approval frameworks.
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Content ArticleThis document provides guidance for maternity services and Local Maternity Systems on how to develop a local plan for achieving Midwifery Continuity of Carer as the default model of care offered to all women. The guidance sets out recommended practice, how delivery against these plans will be assured nationally, and how provision will be measured at provider and Local Maternity System level. Midwifery Workforce Tools designed to help midwifery leaders safely plan, simulate and design maternity services can be used alongside this guidance.
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Content Article
HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance.
