Search the hub
Showing results for tags 'Maternity'.
Found 838 results
-
Content ArticleMBRRACE-UK is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to undertake the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). The aims of the MNI-CORP are to collect, analyse and report national surveillance data and conduct national confidential enquiries in order to stimulate and evaluate improvements in health care for mothers and babies. This report focuses on the surveillance of perinatal deaths from 22+0 weeks gestational age (including late fetal losses, stillbirths, and neonatal deaths) of babies born between 1st January and 31st December 2019.
-
News Article
CQC criticises care scandal trust for 'unsafe staffing'
Patient Safety Learning posted a news article in News
The trust at the centre of a maternity scandal does not have enough midwifery staff to keep women and babies safe, a Care Quality Commission (CQC)inspection has revealed. East Kent Hospitals University Foundation Trust relied on community midwives to fill slots at its acute unit, with some of them working 20-hour days after being called in to help cover and feeling outside of their competence. The trust had suspended a midwife-led unit and diverted women in labour to other hospitals – and when the CQC raised the understaffing issue at its inspection in July, it suspended its home birth service. But the CQC found that the number of midwives and maternity workers on duty rarely matched planned numbers and managers rarely calculated staffing numbers accurately, with some elements of the workload not being factored in. Lack of staff meant there was a risk to the safe assessment and monitoring of women and babies at the trust’s William Harvey Hospital in Ashford. Unqualified staff were having to deal with telephone queries from women who needed advice and support. Read full story (paywalled) Source: HSJ, 15 October 2021 -
Content ArticleThe national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
-
Content ArticleFetal Alcohol Spectrum Disorder (FASD) refers to the range of neurodevelopmental problems caused by pre-natal exposure to alcohol. The effects are diverse and impact on the individual throughout their life course. This document from the Department of Health and Social Care (DHSC) is a health needs assessment for people living with FASD, their carers and families, and those at risk of alcohol-exposed pregnancies in England. The needs identified for this population group focus on: a lack of robust prevalence estimates in England the importance of multi-sector working to support individuals through the life course better training and awareness for health professionals better organisation of services to improve accessibility a need to develop innovative approaches to support those living with the condition.
-
News ArticleA third of stillbirths at two south Wales hospitals could have been prevented with better care or treatment, an investigation has concluded. It emerged two years ago that more than 60 women suffered the heartbreak of a stillbirth at at the Royal Glamorgan, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, and that many of these were never reported or investigated. An independent panel set up by the Welsh Government to oversee improvements in these maternity units has now concluded that many of these babies could have been saved. It looked at whether the care provided to women and their babies between January 2016 and September 2018 fell below the standards expected. The failures were split into different levels of severity, known in the report as "modifiable factors". Their investigation looked at 63 stillbirths between January 1, 2016, and September 30, 2018, and discovered that 21 (33%) of them had at least one "major modifiable factor", meaning the stillbirth could potentially have been avoided. More than half (59%) of the 63 had at least one "minor modifiable factor" while in three-quarters (76%) of them "wider learning" was required. In only four of the 63 stillbirths the panel found no modifiable factors. The panel also discovered that "areas for learning" were identified in 59 of the 63 episodes of care reviewed. Read full story Source: Wales Online, 5 October 2021 Read report
-
Content Article
This is the second in a series of thematic reports to be published by the Independent Maternity Services Oversight Panel about their ongoing programme of independent clinical reviews of the maternity and neonatal care provided by the former Cwm Taf University Health Board. This report focuses on the care of mothers and their babies who were stillborn. It summarises the key themes and issues which emerged from the clinical review of 63 individual episodes of care which were provided by the Health Board between 01 January 2016 and 30 September 2018. -
Content ArticleThis video presents some highlights of the HSJ Patient Safety Awards on 20 September 2021 at Manchester Central, and includes short interviews with some of the judges and award winners. The HSJ Patient Safety Awards were set up to recognise and celebrate projects that improve patient safety and quality of care. This year, the judges commented that nominees across 23 categories were all of a very high quality and presented innovative projects that made real improvements to patient safety in the NHS. "The quality of this year was quite phenomenal - we were really impressed at how inventive people had been in coming up with solutions to COVID as part of safety strategies," said Lesley Durham, President of the International Society of Rapid Response Systems and member of the awards judging panel. The awards showcase excellent projects and ways of working that have potential to be replicated in other areas. A team from Devon Partnership Trust/Royal Devon and Exeter Foundation Trust won the award for Mental Health Initiative of the Year for their project 'Connecting physical and mental health services in Gastroenterology'. A representative from the team said, "What we want to do now is take this, shout about it and make it happen elsewhere." Many award winners commented on the importance of teamwork across services and trusts and recognised that collaboration was a key part of the success of their projects. View the full list of award winners
-
News Article
Baby died after hospital’s ‘catalogue of failings’, NHS inquiry finds
Clive Flashman posted a news article in News
Bristol Children’s hospital tried to ‘deceive’ Ben Condon’s parents about his death, NHS ombudsman says An eight-week-old baby died after “a catalogue of failings” in his treatment at a children’s hospital, which then tried to “deceive” his parents about his death, an official inquiry has found. Doctors failed to spot that Ben Condon was suffering from a deadly bacterial infection and did not give him antibiotics until an hour before he died, the NHS ombudsman said. “We found that Ben and his family suffered serious injustice in consequence of the failings we found in his care and treatment,” the parliamentary and health service ombudsman said in a report that contained damning criticisms of Bristol Children’s hospital. The errors were all “lost opportunities” to help Ben recover from his illness and so increased the risk of him dying. Read the full article here Source: The Guardian Also covered in the Independent -
News Article
£7.5m Covid-19 vaccine study for pregnant women launches in Manchester
Clive Flashman posted a news article in News
The country’s largest clinical study is being launched in Greater Manchester to investigate the best gap between first and second Covid-19 vaccine doses for pregnant women. Led by St George’s, University of London, the Preg-CoV study will provide vital clinical trial data on the immune response to vaccination at different dose intervals – either four to six weeks or eight to 12 weeks. This data will help determine the best dosage interval and reveal more about how the vaccine works to protect pregnant mothers and their babies against Covid-19. Pregnant women are more likely to develop severe Covid-19 or die from the disease but are excluded from clinical trials with new vaccines. This means there are currently very limited clinical trial data on the immune response and side effects caused by the vaccines for these women. Read the full story here Source: National Health Executive -
Content ArticleOn Friday 17 September 2021 the World Health Organization (WHO) held their World Patient Safety Day 2021 Virtual Global Conference, focused on the theme of ‘Safe maternal and newborn care’. This page contains links to a number of presentations from the event.
-
Content ArticleIn this blog, Mabel Prendergast reflects on key themes discussed at the Institute of Global Health Innovation's (IGHI) third World Patient Safety Day event on the 17 September 2021, with the theme of safer maternal and newborn care. This virtual event was chaired by Dr Mike Durkin, IGHI’s Senior Advisor on Patient Safety Policy and Leadership, and included a range of speakers and panellists.
-
Content Article
House of Commons Debate - Baby Loss Awareness Week (23 September 2021)
Mark Hughes posted an article in Maternity
This is the transcript of a debate in the House of Commons ahead of Baby Loss Awareness Week (9 to 15 October 2021). In this debate, MPs reflected on personal experiences and those of their constituents, the role of Baby Loss Awareness Week as an essential focal point for bereaved families and the potential for the Government to mandate and fund the National Bereavement Care Pathway programme. -
Content ArticleThis is the Government’s formal response to the recommendations made by the Health and Social Care Committee in its report, ‘The Safety of Maternity Services in England’. The Committee’s inquiry examined evidence relating to the safety of maternity services. It builds upon current investigations following incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. The inquiry also considered whether the clinical negligence and litigation processes need to be changed to improve the safety of maternity services and explored the impact of blame culture on learning from incidents.
-
Content ArticlePrisons and Probation Ombudsman Sue McAllister has published the independent investigation into the death of a baby (Baby A) at HMP Bronzefield on 27 September 2019. The investigation identified a considerable number of issues and concerns about the care and management of Ms A, the baby’s mother. Sue makes a significant number of recommendations to improve maternity services in Bronzefield. There is wider learning for the whole of the women’s prison estate from the death of Baby A, and the Prison Service must take this opportunity to improve the outcomes for pregnant prisoners so that this tragic event is not repeated.
-
News ArticleA catalogue of failures among prison and health professionals has been highlighted in an investigation report into the death of a teenager’s baby after she gave birth alone in her cell at the largest women’s prison in Europe. The Prisons and Probation Ombudsman published the devastating report into the events in September 2019 at HMP Bronzefield in Ashford, Middlesex on Wednesday. The case was first revealed by the Guardian and the baby’s death triggered 11 separate inquiries. The report details a disturbing series of events that culminated with the young woman, who cannot be named, being in “constant pain” on the night of 26 September and eventually passing out while giving birth. According to the report the teenager "appeared to have been regarded as difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year-old, frightened that her baby would be taken away”. Failings included: There was confusion among different health professionals about her due date. The day before her baby was born she told a prison nurse she would kill herself or someone else if the baby was taken away from her, but this information was not adequately shared. On 26 September she was put on extended observation, meaning she should have been regularly checked but this did not happen. She rang the bell twice at 8.07pm and 8.32pm that day. A call was connected then immediately disconnected at 8.45pm. She did not press the bell again. Checks by prison officers at 9.27pm and 4.19am revealed “nothing untoward”. It was left to two prisoners to alert staff to the fact that there was blood in her cell at 8.21am on 27 September. Prisons and Probation ombudsman Sue McAllister said: “Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened. Overall, the healthcare offered to Ms A in Bronzefield was not equivalent to that she could have expected in the community.” The publication of the report has triggered multiple calls for an end to the imprisonment of pregnant women from the Royal College of Midwives, NGOs and academics in the field. Read full story Source: The Guardian, 22 September 2021
-
Content Article
In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships. -
News Article
Troubled maternity wards still jeopardising patients, watchdog warns
Patient Safety Learning posted a news article in News
Babies and mothers are at risk of injury and death because too many maternity units have not improved care despite a string of childbirth scandals, a Care Quality Commission (CQC) report has warned. In a highly critical report published on Tuesday, the CQC voiced serious concern that lessons are not being learned and that many incidents involving patients’ safety are still not being recorded. Some hospitals have been “too slow” to take the steps needed to make labour and birth safer, despite multiple inquiries, reports and recommendations to do so, it said. The CQC also found other persistent weaknesses in maternity care, including tension and difficulties between obstetric doctors and midwives and poor oversight of risks to patients during an in-depth inspection of maternity care at nine hospitals in England. The NHS has been criticised for major maternity scandals involving poor care, which sometimes persisted for many years, at trusts such as Morecambe Bay, East Kent and Shrewsbury and Telford. The government, NHS leaders and patients have pressed the NHS in England to overhaul maternity safety to reduce the number of babies being left brain-damaged or dead and mothers injured or dead as a result of poor care during childbirth. The watchdog also criticised hospitals for doing too little to seek the views from black, minority ethnic and poorer communities about how to improve their experience of giving birth. Black women are four times more likely to die in childbirth than white women, and Asian women twice as likely. “We know that many maternity services are providing good care, but we remain concerned that there has not been enough learning from good and outstanding services,” said Ted Baker, the regulator’s chief inspector of hospitals. Read full story Source: The Guardian, 21 September 2021 -
News Article
‘Worrying failings’ in the administration of the NHS maternity charging programme
Patient Safety Learning posted a news article in News
Maternity Action’s new research has found worrying failings in the administration of the NHS charging programme, leaving vulnerable women anxious and fearful about debts they cannot pay and deterring them from attending for care. Maternity Action’s new report Breach of Trust: a review of the implementation of the NHS charging programme in maternity services in England details how the implementation of the government’s NHS charging ‘overseas visitors’ programme within NHS Trusts poses a significant risk to migrant women’s health and wellbeing. The government insists that women who are vulnerable are adequately protected because the regulations make certain vulnerable groups exempt from NHS charging, such as refugees, asylum seekers, women who have been victims of modern slavery. The government have also stated that all maternity care should be deemed ‘immediately necessary’ and not refused due to an inability to repay. However the report has found that these legal safeguards are simply not working upon implementation in Trust settings. Many migrant women living in the UK are put at risk because they are deterred from accessing essential maternity care. Read full story Source: Maternity Action, 16 September 2021 -
News Article
Unsafe maternity care has cost the NHS £8.2bn in 15 years
Patient Safety Learning posted a news article in News
Negligent maternity care in the NHS has cost taxpayers an “eye-watering” £8.2bn over the past 15 years, The Independent reveals. Ministers face calls to urgently increase spending to ensure maternity units are safe for women and babies by providing adequate staffing levels, training and equipment. New data, obtained by The Independent from NHS Resolution, which handles clinical negligence costs for the service, reveals that total payments made following settled cases and legal costs rose from £271m in 2006-07 to an estimated £920m in 2020-21. The number of maternity claims being made by families has almost doubled in the past decade, rising from 391 in 2009-10 to 765 in 2019-20. Recent maternity scandals at the Shrewsbury and Telford Hospital Trust, East Kent Hospitals University Trust and at hospitals in Nottingham have all had common themes around poor culture, a lack of honesty and not enough staff or equipment. The Department of Health and Social Care is exploring how it can make changes to the UK clinical negligence system to reduce the costs to the taxpayer. Health minister Nadine Dorries told MPs on the Commons health committee in February that the reforms would look “across the NHS… not just maternity, at how issues of no-blame, no-fault compensation and clinical negligence are treated”. Read full story Source: The Independent, 20 September 2021 -
News Article
Folic acid to be added to UK flour to help prevent birth defects
Patient Safety Learning posted a news article in News
Folic acid is to be added to UK flour to help prevent spinal birth defects in babies, the government will announce. Women are advised to take the B vitamin - which can guard against spina bifida in unborn babies - before and during pregnancy, but many do not. It is thought that adding folic acid to flour could prevent up to 200 birth defects a year. Mandatory fortification - which the government ran a public consultation on in 2019 - would see everybody who ate foods such as bread getting more folic acid in their diets. Neural tube defects, such as spina bifida (abnormal development of the spine) and anencephaly, a life-limiting condition which affects the brain, affect about 1,000 pregnancies per year in the UK. Many babies diagnosed with spina bifida survive into adulthood, but will experience life-long impairment. Kate Steele, chief executive of Shine, a charity providing specialist support for people affected by spina bifida and hydrocephalus and which has campaigned for mandatory fortification of flour for more than 30 years, said she was "delighted" by the decision. "In its simplest terms, the step will reduce the numbers of families who face the devastating news that their baby has anencephaly and will not survive," she said. "It will also prevent some babies being affected by spina bifida, which can result in complex physical impairments and poor health." Read full story Source: BBC News, 20 September 2021 -
Content ArticleFor World Patient Safety Day, Natasha Swinscoe, Patient safety national lead for the AHSN Network and CEO, West of England AHSN, highlights the difference the AHSNs and Patient Safety Collaboratives have made in safe maternal and newborn care.
-
Content Article
The Patients Association: World Patient Safety Day 2021
Patient Safety Learning posted an article in Maternity
While childbirth in the UK is generally a safe event, progress to improve safety seems to have stalled, and how safe mums and babies are depends on where you are and who you are, writes the Patients Association in this article for World Patient Safety Day. The Patients Association firmly believe that involving patients in their care improves outcomes and safety. Mums-to-be developing plans with the midwives and obstetricians seems a perfect example of this. However, research shows that clinicians meaningfully partnering with patients is not mainstream practice. "It will take leadership, training and funding to make patient partnership in maternity care everyday practice", says the Patient Association. "This World Patient Safety Day we call on all those in a position to bring about change in how maternity care is delivered and to pledge to introduce true patient partnership." -
Content Article
World Patient Safety Day 2021
Patient Safety Learning posted an article in Maternity
In this blog Patient Safety Learning marks World Patient Safety Day 2021. It sets out the scale of avoidable harm in healthcare, what needs to change to create a patient safe future and considers the theme of this year’s World Patient Safety Day, ‘Safe maternal and newborn care’. -
News Article
Pandemic changes affected maternity care for women who had stillbirths
Patient Safety Learning posted a news article in News
Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its findings the watchdog said staffing levels were affected because of the NHS response to the pandemic. In its report it said this “influenced normal work patterns and the consistency and availability of clinicians.” As an example, in one maternity unit the staffing numbers were short by three midwives due to sickness and redeployment. In another consultant presence was reduced overnight. During the pandemic both the Royal College of Midwives and the Royal College of Obstetricians criticised NHS trusts for redeploying maternity staff when mothers continued to need services regardless of the pandemic. HSIB said none of the women in its report were recorded as having the virus, but it found the pressures and changes as a result of the pandemic may have affected the care they received. The study stressed that the proportion of consultations undertaken remotely was not known and "the impact of remote consultations is not clear from this review". Read full story Source: The Independent, 16 September 2021 -
Content ArticleThe number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year. The data initiated a HSIB national learning report, which explores the findings from their maternity investigations during this time. They investigated intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.
