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Found 838 results
  1. Event
    During pregnancy, labour and delivery many First Nations, Inuit and Métis people experience significant barriers to accessing care thus leading to unacceptable health disparities including increased risk for poor maternal and newborn health outcomes in Canada. There are opportunities to improve maternal and infant health outcomes. Join this webinar with the National Aboriginal Council of Midwives and Patients for Patient Safety Canada, a patient-led program of Healthcare Excellence Canada, in honour of World Patient Safety Day. The goals of this virtual discussion are to build awareness and understanding of the experiences of First Nations, Inuit and Métis, and to discuss ways to provide safer maternal and newborn care. The perspectives and experiences of patients, providers and researchers on the current patient safety challenges will be shared, as well as the supports and strategies to improve outcomes and experiences.  This session will also identify what health care providers and leaders can do to improve First Nations, Inuit and Métis safety and health outcomes.  All will leave the session practical ideas to improve patient safety with and for Indigenous families. Register
  2. Content Article
    The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Recently there has been greater research attention on patient safety in low- and middle-income countries due to the global awareness of the need to improve safety standards for all patients, including in maternal care. In this blog, I highlight the scale of maternal and newborn death in low- and middle-income countries, the contributing factors to this, and the need to improve maternal health and safety.
  3. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This month, to mark World Patient Safety Day 2021 on the 17 September, we’ve selected seven resources related to this year’s theme, ‘Safe maternal and newborn care’. Shared with us by hub members, charities and patient safety advocates, they provide valuable insights and practical guidance on a broad range of maternity safety topics. 
  4. Content Article
    This joint letter calls on Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, to urgently fund a confidential enquiry into the deaths of Asian and Asian British babies. It is signed by the Chief Executives of Sands, The Royal College of Midwives, NCT and the President of the Royal College of Obstetricians and Gynaecologists.
  5. Content Article
    Derek Richford talks to Rob Behrens about the loss of his newborn grandson, Harry, at East Kent Hospitals University Trust. He explains how his sheer persistence uncovered the truth of what went wrong and eventually led to a criminal investigation at the Trust. He also tells us what organisations involved in the complaint process can learn from his family's tragic experience.
  6. News Article
    A hospital has admitted liability for the death of a baby who was delivered stillborn three days after his mother’s complaints of fluid loss and severe pain were dismissed as wetting the bed. Jacob Jackson could have been born healthy, Shrewsbury and Telford hospital trust (Sath) has accepted, if it had arranged an earlier delivery in October 2018 as his mother, Charlotte, had suggested. The incident happened 18 months after an external review had been ordered into serious maternity failings at the trust, which are now known to be the biggest maternity scandal in the history of the NHS. Charlotte said: “It makes me feel sick to my stomach that they knew there were problems – this sort of thing had been going on for decades. We keep getting fed the same lines that ‘lessons have been learned’. If lessons had been learned parents and babies wouldn’t be going through this.” Read full story Source: The Guardian, 6 September 2021
  7. Event
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    This event will mark the 2021 World Health Organisation’s World Patient Safety Day and aims to showcase the patient safety work happening in the NHS and with partners, to improve the safety of maternal and neonatal care. Speakers: Introduction from Aidan Fowler, National Director of Patient Safety (chair) Presentations from the National Maternity Champions, Matthew Jolly, National Clinical Director for Maternity and Women's Health and Professor Jacqueline Dunkley-Bent OBE, Chief Midwifery Officer Hear from AQUA (the Advancing Quality Alliance) about its safety culture programme for maternity and neonatal board safety champions Dr Nicola Mackintosh, Associate Professor in Social Science Applied to Health, SAPPHIRE Deputy, University of Leicester will present on ‘What a good maternity safety culture looks like’, providing an overview of a considered analysis of maternity and neonatal safety culture surveys Tony Kelly, National Clinical Lead for the Maternity and Neonatal Safety Improvement Programme will provide an introduction to the national Maternity Early Warning Score (MEWS) tool and Newborn Early Warning Trigger and Track (NEWTT) Expected Audience: NHS provider and commissioning staff, particularly those working in maternity and neonatal care and in patient safety roles. Register
  8. Content Article
    The Royal College of Midwives (RCM) has warned that measures to reduce pressure on maternity services are putting safety at risk. In a letter to Jacqueline Dunkley-Bent, Chief Midwifery Officer at NHS England, the RCM acknowledges the effectiveness of some measures to relieve pressure on staff and services, but expresses concern at others.
  9. News Article
    Glen Burley, an acute trust chief executive has said NHS England risks ‘levelling down’ safety in some maternity services by ‘disproportionately’ directing additional funding to struggling trusts. This comes after NHS England said the funding prioritised the trusts which needed the most support to meet the essential actions in the Ockenden Report, where in March, NHSE invited trusts to bid for a share of £96m extra funding for maternity services. A spokeswoman for NHS England has said: “The NHS made an additional £96m investment in maternity services following the Ockenden Review, the majority of which will bolster the workforce by funding an additional 1,200 midwives and 100 obstetricians. While the funding for additional workforce is for all NHS trusts, it is right that those who most need the support are prioritised.” Read full story. Source: HSJ, 02 September 2021
  10. Content Article
    In this blog Patient Safety Learning looks ahead to World Patient Safety Day 2021 and considers its theme, ‘Safe maternal and newborn care’.
  11. News Article
    A same-day blood test that can rule out pre-eclampsia, in pregnant women is being rolled out across the NHS in England. The test, known as placental growth factor (PLGF) testing, is already being used in three quarters of maternity units in England. NHS clinical director for maternity and women‘s health Matthew Jolly said: “Pre-eclampsia is a life-threatening condition for both mum and baby if left untreated and this is why the NHS takes every precaution possible when soon-to-be mums have some of the early signs, like high blood pressure. This new way of testing means we can rule out the condition in a much quicker and easier way - it removes the stress that comes with the uncertainty around not having a diagnosis and will reassure thousands of pregnant women every year.” Read full story. Source: The Independent, 25 August 2021
  12. News Article
    Nottingham University Hospitals Trust has been served with a section 29a warning notice by the Care Quality Commission requiring it to ensure a ‘more positive culture’. A CQC spokeswoman confirmed: “The trust was issued with a warning notice requiring it to take action to improve corporate and clinical governance and oversight of risk, and to ensure a more positive, open and supportive culture across the organisation. We will report on the full findings from the inspection as soon as we are able to.” Although it is still not clear why the warning was issued, the trust is currently engaged in concerns over their accident and emergency department and maternity services. “We accept the CQC’s comments and work is already underway to learn from the findings and make improvements so that the organisation is led as effectively as possible and we continue to provide world class care for our patients.” Nottingham University Hospitals Trust acting chief executive and chief finance officer Rupert Egginton has said. Read full story (paywalled). Source: HSJ, 18 August 2021
  13. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2020/21, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken.
  14. News Article
    1,500 safety recommendations have been made to NHS trusts a year after hundreds of babies were left brain damaged and dozens of mothers and infants died. Safety watchdog Healthcare Safety Investigation Branch (HSIB) has outlined key themes from 760 investigations of maternity incidents, taking over investigations for NHS trusts in 2018 after concerns were raised over the poor quality of investigation by trusts and a lack of involvement in families. Sandy Lewis, associate director of maternity said: “The publication of the HSIB maternity programme year review provides crucial details of the work that has been undertaken in the last year. We would like to thank all of those who have worked with us in the past year, sharing their experiences, insights and expertise. Many families have not only told us their stories but have also trusted our investigators to reflect their perspectives and share their experience. Trusts have responded promptly to this insight, this has contributed to improving safer care of mothers, babies and families across the country.” Read full story. Source: The Independent, 16 August 2021
  15. News Article
    At a virtual event held by The Independent last night, experts agreed maternity services needed to be overhauled. The panel discussion, NHS maternity scandal: Inside a crisis, laid out the facts surrounding the problems around maternity care and concerns around safety amid repeated examples of poor care in multiple cases. Donna Ockenden, a senior midwife who has been leading the inquiry into maternity services at Shrewsbury and Telford Hospitals explained "I think one of the major issues around maternity services is that we’re not treated in the same way as A&E. I think that people fail to see that actually, maternity is a woman’s A&E department, you can start a shift in any maternity unit, you can plan what you think you’re going to do. But actually you don’t know what is going to come in the front door.” Read full story. Source: The Independent, 12 August 2021
  16. Content Article
    The Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals:  The Royal Glamorgan hospital Prince Charles hospital The report makes recommendation on improvements to ensure the safety of mothers and babies. "During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action." "The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."
  17. Content Article
    The Royal College of Midwives is calling for "common sense" from NHS trusts and boards on staff access to water and other drinks. The college is concerned that the health and wellbeing of midwives could be in jeopardy as a result of having limited opportunities to stay hydrated on long, hot shifts. .In new guidance to its members, the RCM sets out the importance of staying hydrated on shift and the potential implications of not doing so. These included an impact on decision making, memory, attention span, mood and tiredness. The document also debunks myths suggesting that having fluid bottles on units is a cross infection risk.
  18. Content Article
    Do all your staff receive training for the management of anaphylaxis as part of their mandatory training? Do you have a specific maternal cardiac arrest emergency call to include obstetricians and neonatologists? Do all resuscitation trolleys in your trust have a scalpel and umbilical cord clamps as an essential kit requirement? Are you aware of the obstetric cardiac arrest quick reference guide from the Resus Council, OAA and MBRRACE? Obstetric cardiac arrest is rare but devastating. This quick reference guidance, produced by Resuscitation Council UK and Obstetric Anaesthetists’ Association (and endorsed by MBRRACE), has been developed to aid Advanced Life Support providers response to this. It aims to help structure the team response, with reminders of modifications required for the pregnant patient and causes of cardiac arrest to consider.
  19. News Article
    After an unannounced inspection at the Princess Alexandra Hospital Trust in June, the Care Quality Commission (CQC) found an “emergency c-section was being performed without the correct equipment available to monitor the mother”. According to reports, the inspectors stepped in immediately to raise concerns, which was then corrected straight away. In a letter to the trust, the CQC wrote, “Overall, we were concerned that the safety culture in the service was underdeveloped. There were no dedicated maternity safety huddles in line with national guidance. Handovers doubled up as safety huddles. During our observations of handovers, we saw that staff did not discuss safety issues and the format was not safety focused.” Read full story (paywalled). Source: HSJ, 6 August 2021
  20. Event
    At a time when the NHS is struggling unprecedently, having been battling a pandemic for 18 months, one of the most concerning areas is the state of maternity services at trusts around the country. It has been uncovered following recent investigations by the Independent newspaper's health correspondent Shaun Lintern that the scale of the problem is putting the lives of both mothers and babies at risk on a daily basis. To explore the apparent crisis existing within our hospitals Shaun will be hosting a live panel discussion with maternity experts who have experience of the situation from within the NHS as well as elsewhere. The speakers will help explain what has gone so wrong, what impact it has had and what lasting effects there might be, as well as what the future holds and if the scandal has at least ensured improvements are now in place and our maternity services are becoming safer for all who use them. The panel will include Donna Ockenden, the chair of Shrewsbury inquiry and Senior Midwifery Adviser, Gynaecologists president Edward Morris and James Titcombe, OBE and ambassador for charity Baby Lifeline; Associate Editor, Journal of Patient Safety and Risk Management and campaigner who helped expose poor care at University Hospitals Morecambe Bay Trust following the death of his son Joshua. Register
  21. Content Article
    People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Many of the recommendations in the Ockenden report were already covered by national guidance, Susan Stanford asks why the guidance wasn’t followed and whether it might not be being followed elsewhere.
  22. Content Article
    This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting."
  23. News Article
    Jacqueline Dunkley-Bent, England's chief midwife has sent a letter to midwives, obstetricians and GP practices urging them to encourage pregnant women to get double-vaccinated. "Vaccines save lives, and this is another stark reminder that the Covid-19 jab can keep you, your baby and your loved ones, safe and out of hospital." Dunkley-Bent has said and recommends advice on jabs be offered at every opportunity. Read full story. Source: BBC News, 30 July 2021
  24. Content Article
    This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units.
  25. Content Article
    Pregnant people receive many public health messages that are intended to guide their decision making; intended to improve outcomes for babies and mothers. However, there is growing concern that messages do not always fully reflect or explain the evidence base underpinning them, and that negotiating the risk landscape can sometimes feel confusing, overwhelming, and disempowering. This may negatively affect women’s experiences of pregnancy and motherhood, and be exacerbated by a wider culture of parenting that tends to blame mothers for all less-than-ideal outcomes in their children. The WRISK Project draws on women’s experiences to understand and improve the development and communication of risk messages in pregnancy.
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