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Found 838 results
  1. Content Article
    The Maternal and Neonatal Health Safety Collaborative (MNHSC), is providing each maternal and neonatal service with an opportunity to assess their safety culture as part of the programme of improvement work across England. Organisations within each wave of the collaborative will be given the opportunity to undertake a culture survey, and then a repeat survey after 12-18 months. The culture of an organisation, team and staff attitudes can have a tangible impact on patient safety and outcomes. There is great value in assessing the safety culture; the results can inform the local improvement plans. The organisation will be supported through the process. This document explains more about the SCORE survey, what it measures, and what it means for the team and improvement projects. 
  2. News Article
    An inquiry into dozens of baby deaths at an NHS trust will examine failings from “ward to board” covering a period of more than a decade, it has emerged. The independent inquiry into poor maternity care at East Kent Hospitals University Trust published its terms of reference and scope for how it will carry out its work on Thursday. The probe, led by Dr Bill Kirkup, was commissioned by the government after The Independent revealed more than 130 infants suffered brain injuries during birth at the trust over several years. The scandal was exposed by the family of baby Harry Richford who died after a catalogue of errors by maternity staff in November 2017. A coroner ruled his death was the result of neglect and “wholly avoidable”. Several other families have also spoken out over the deaths of their babies, with evidence emerging the trust’s managers were warned about safety concerns but failed to take action. In October, the Care Quality Commission (CQC) said it intended to prosecute the trust over the death of Harry Richford. It is understood that since the inquiry was launched, a significant number of families have come forward with concerns but the inquiry has refused to say what the total number of cases is. Read full story Source: The Independent, 11 March 2021
  3. Content Article
    A new study from Praharaj and Stanciu provides guidance for clinicians discussing the risks of ADHD medications with their pregnant patients.
  4. News Article
    Former staff at a Midlands acute trust have raised concerns over a ‘toxic management culture’ and ‘unsafe’ staffing levels within its maternity services, HSJ has learned. Two clinicians who recently worked within Sandwell and West Birmingham Hospital Trust’s maternity department have sent a letter to the Care Quality Commission outlining a series of concerns. The letter, seen by HSJ, claimed there was a “toxic management culture alongside poor leadership” within the trust’s senior midwifery team. It added: “This had led to 100 per cent turnover in staff within the middle management line… There is no confidence in the current leadership structure and no confidence that staff will be listened to and heard.” HSJ also understands there are also concerns around the service within the trust’s management. Although they do not raise direct patient safety concerns, the clinicians said the problems were “mostly long-standing” and had “deteriorated to the point where there is now a risk to patient safety”. They added: “We are raising these concerns now with the CQC as we feel we have not been listened to and changed effected in a timely manner.” Read full story (paywalled) Source: HSJ, 10 March 2021
  5. Event
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    This Westminister Health Forum policy conference will discuss opportunities and priorities for the third sector in supporting maternity services, with contributions from Helen Hughes, Chief Executive Officer, Patient Safety Learning, and Dr Clea Harmer, Chief Executive, Sands. Overall, areas for discussion include: the Ockenden Review and the NHS Long Term Plan - progress and outstanding issues in meeting recommendations and ambitions relating to maternity care care during COVID-19 - adjustments in delivery, lessons learned, and possible directions for post-pandemic maternal care and recovery of services health inequalities - looking at priorities for how they can be addressed and improving support key issues for innovation, safety and regulation. The discussion is bringing together stakeholders with key policy officials who are due to attend from the DHSC and the Health Inspectorate Wales, as well as parliamentary pass-holders from the House of Commons - Health and Social Care Committee. Agenda Register
  6. News Article
    A baby boy was starved of oxygen and died after being left half-delivered for almost a quarter of an hour during a “chaotic” breech birth in an NHS maternity unit. Midwives failed to recognise baby Theo Ellis was in the breech, or bottom first, position until his mother Laura Ellis, 34, was already in advanced labour at Surrey’s Frimley Park Hospital. What followed was a catalogue of errors by midwives and doctors who failed to heed the emergency situation and raised the alarm too late. At one stage a paediatrician was made to stand outside the room by midwives while junior staff struggled to deliver Theo alone. A senior obstetrician was in surgery and a miscommunication by midwives and an on-call consultant meant she did not arrive until Theo was already dead. After his parents brought legal action against the NHS, Frimley Park Hospital has now admitted mistakes led to Theo’s death in April 2019. Ms Ellis and husband James are angry their son was classed as being stillborn which meant a coroner was not allowed to investigate his care during an inquest. There have been repeated calls to change the law to ensure the deaths of babies like Theo are investigated. His mother told The Independent: “I walked in with a healthy baby. I’d looked after him for nine months and they killed him in the process of giving birth. The hospital get to write that he was stillborn, which obviously is a huge benefit to them, because the coroner can’t get involved, which to me is just staggering." Read full story Source: The Independent, 9 March 2021
  7. News Article
    NHS hospitals have been forced to pay millions of pounds to regulators after wrongly claiming their maternity units were among the safest in the country. Seven NHS trusts, including some now at the centre of major care scandals, will have to pay back a total of £8.5m after self-assessments of their maternity services were found to be false. Families whose babies died as a result of avoidable errors at some of the hospitals told The Independent it was further evidence of poor governance and management failings. NHS Resolution, which acts as the health service’s insurer for clinical negligence, launched the maternity incentive scheme in 2018 in an effort to focus action on 10 key safety areas in maternity, including ensuring they have systems in place to review deaths, monitor women and plan staffing levels as well as reporting incidents to the Healthcare Safety Investigation Branch which investigates maternity incidents in the NHS. Among the trusts forced to give money back over the first two years of the scheme include Shrewsbury and Telford Hospital Trust, which paid back £953,000. An inquiry into its maternity service found a dozen women and more than 40 babies died as a result of poor care in one of the largest maternity scandals in NHS history. East Kent Hospitals University Trust, which is facing an inquiry into baby deaths and a criminal prosecution by the Care Quality Commission over the death of baby Harry Richford in 2017, face paying back £2.1m over two years. Derek Richford, who helped expose failings at East Kent after the death of his grandson, told The Independent it was “abhorrent” that the trust claimed “vital NHS funds by falsely claiming that they had achieved 10/10 for maternity safety when the truth was in fact 6/10. East Kent Trust did this two years running and even when asked to check their submission, reconfirmed the erroneous data to NHS Resolution.” An evaluation of the scheme by NHS Resolution said it was “recognised that recent examples of poor governance from trusts in relation to the certification of submissions require further action”. Read full story Source: The Independent, 7 March 2021
  8. Content Article
    This guide aims to help staff and services understand the impact of psychological trauma on women in the perinatal period and respond in a sensitive and compassionate way. It aims to support staff to ensure they ‘do no harm’ through care delivery that, without thought or intention, could retraumatise individuals. This includes examples of how to: recognise and understand the impact of psychological trauma and how experiences may present during the perinatal period respond to disclosures and tailor care to needs of women and families so that services do not retraumatise individuals best support staff working in maternity and mental health services, acknowledging the effects of vicarious trauma and that staff may have their own experiences of trauma, which could impact on their capacity to deliver trauma-informed care.
  9. Content Article
    This was a debate in the House of Lords on the 2 March 2021 concerning the UK Government's plans regarding a redress scheme for those harmed by sodium valproate, stemming from recommendations in the First Do No Harm Report by the Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege (also known as the Cumberlege Review).
  10. Content Article
    The Healthcare Safety Investigation Branch (HSIB) carried out a themed review of their maternal death investigations during the coronavirus (COVID-19) pandemic. The national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety. Explore wider patient safety processes.
  11. News Article
    Staff at a Midlands hospital trust told regulators they had repeatedly raised safety concerns internally without action being taken. The Care Quality Commission (CQC) has downgraded maternity services at Worcestershire Acute Hospital from “good” to “requires improvement” following an inspection prompted by the whistleblowers’ concerns. Staff had reported “continuously escalating” staffing level concerns to senior managers, but said they got “no response”. Some said they were fearful of raising concerns internally. Whistleblowers also reported delays to induction of labour, with examples of women waiting up to a week to be induced instead of one to two days. Managers said women who suffered delays were risk assessed. The CQC also identified a risk women might not be informed of significant harm caused to them or their babies following an incident, due to the way the trust was grading some babies who were admitted to the neonatal unit. However, it added: “When things went wrong, staff apologised and gave patients honest information and suitable support.” The report added the trust’s leaders were aware of the challenges in maternity, but “timely” action was not always taken to address the concerns. Read full story (paywalled) Source: HSJ, 19 February 2021
  12. Content Article
    This blog, published on the Maternity Experience website, is written by Gill Phillips Director of Nutshell Communications Ltd and creator of the Whose Shoes?® concept and principles. Through her facilitation work, Gill helps people get to the heart of what is important in communication and co-production. Instead of wrapping things up in jargon and complicated language, messages are honest, direct and simple, sourced from what real people are saying. In this blog, Gill talks about the networks that have come together over the past year to explore baby loss and how this work is enabling diverse conversations, rich discussions and a shared commitment to continue improving services for families who experience bereavement.
  13. News Article
    NHS guidance which often forces pregnant women who test positive with coronavirus to give birth alone is legally wrong, lawyers warned. Official guidance drawn up by NHS England states that if a woman tests positive for Covid, their husband or partner must self-isolate at home and is not allowed to support them during childbirth. But campaigners and lawyers told The Independent their guidance for visitor restrictions in maternity services during the pandemic is legally inaccurate as people have the “right to private and family life” under Article Eight of the Human Rights Act. Maria Booker, of Birthrights, a leading maternity care charity, said: “The NHS oversimplifies the government’s self-isolating Covid regulations and tells partners they have to stay at home. But this hasn’t taken into account the legal nuance that government rules state people can leave home if they have a reasonable excuse." “A woman being anxious about giving birth alone, which most people will be, is likely to legally constitute as a reasonable excuse." “It is completely inhumane for a woman to give birth without a partner or supporter. It is even scarier giving birth alone you are Covid positive. It is terrifying. Nobody should give birth alone and that includes Covid positive women.” Read full story Source: The Independent, 13 February 2021
  14. Content Article
    'Continuity of carer' in midwifery is when a woman has consistency in who they see during their pregnancy, labour and postnatal period. In this video, three midwives share their experiences of working in this way and talk about the benefits they've seen for women, babies and their own practice. They provide examples of how this model can improve the safety of services and offer advice for teams and individuals embarking on the continuity of carer journey. 
  15. Content Article
    NHS Providers letter to the Health and Social Care Committee calls for sufficient extra recurrent funding to implement the Ockenden recommendations properly and fully.
  16. News Article
    Making maternity wards safer for mothers and babies will need £400m of extra spending every year, hospital leaders have told The Independent. They warn that without increased funding, the NHS will not be able to fully implement recommendations made by an inquiry into poor maternity care at the Shrewsbury and Telford Hospitals Trust – where dozens of babies died or were left brain damaged in the largest maternity scandal in NHS history. Multiple maternity care failings at hospitals across the country in the past 12 months have sparked concerns over the safety of mothers and their babies with MPs on the Commons Health Select Committee launching an investigation into the issue last year. Hospital leaders say even just covering existing shortfalls of 3,000 midwives and recruiting 20 per cent more obstetricians, will cost at least £250m a year. To pay for extra anaesthetists, neonatal nurses and other support staff could push the cost to more than £400m. Chris Hopson, chief executive of NHS Providers, which represents hospital trusts, told The Independent that ministers faced a choice of either making the extra cash available or forcing the NHS to cut money elsewhere. In a letter to MPs on the committee, Mr Hopson urged them to demand extra funding in its forthcoming report on maternity safety in an effort to force ministers to confront the issue. Read full story Source: The Independent,9 February 2021,
  17. News Article
    An urgent inquiry to investigate how alleged systemic racism in the NHS manifests itself in maternity care will be launched on Tuesday with support from the UK charity Birthrights. The inquiry will apply a human rights lens to examine how claimed racial injustice – from explicit racism to bias – is leading to poorer health outcomes in maternity care for ethnic minority groups. Data published last month by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the country) showed black women were four times more likely than white women to die in pregnancy or childbirth in the UK while women from Asian ethnic backgrounds face twice the risk. Barrister Shaheen Rahman QC, who will lead the inquiry, said: “In addition to these stark statistics there are concerns about higher rates of maternal illness, worse experiences of maternity care and the fact black and Asian pregnant women are far more likely to be admitted to hospital with COVID-19. “We want to understand the stories behind the statistics, to examine how people can be discriminated against due to their race and to identify ways this inequity can be redressed.” Read full story Source: The Guardian, 7 February 2021
  18. Content Article
    This is the first in a series of thematic reports which will be published by the Independent Maternity Services Oversight Panel in the coming year. The purpose of the report is to summarise the learning which is emerging from the ongoing programme of independent clinical reviews of the maternity and neonatal care previously provided by the former Cwm Taf University Health Board. This particular report summarises the key themes and issues which emerged from the clinical review of 28 individual episodes of care1 which were provided by the Health Board between 01 January 2016 and 30 September 20182. It focuses on the care of mothers who needed unplanned emergency treatment during childbirth, including some who required admission to an Intensive Care Unit.
  19. Event
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    This Westminster Health Forum policy conference will examine next steps for maternity services in England. Areas for discussion include: the Ockenden Review and the NHS Long Term Plan - progress and outstanding issues in meeting recommendations and ambitions relating to maternity care care during COVID-19 - adjustments in delivery, lessons learned, and possible directions for post-pandemic maternal care and recovery of services health inequalities - looking at priorities for how they can be address and improving support key issues for innovation, safety and regulation. Agenda Register
  20. News Article
    Failures to follow national guidelines to prevent group B Strep infections in newborn babies is leading to a postcode lottery of care and opportunities to stop deadly infections being missed, a new report has found. Nearly 90% of hospitals in the UK are not using the recommended test for GBS carriage – which costs around £11- despite clear guidance issued by the Royal College of Obstetricians and Gynaecologists (RCOG) and Public Health England (PHE) that the test can significantly decrease false-negative results. Group B Strep is the UK’s most common cause of severe infection in newborn babies, causing sepsis, pneumonia, and meningitis. Approximately 800 babies a year in the UK develop group B Strep infection in their first 3 months of life, 50 babies will die, with another 70 survivors left with life-changing disabilities. Most of these infections could be prevented. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Read full story Source: Group B Strep Support, 1 February 2021
  21. Content Article
    The Royal College of Obstetrics and Gynaecology (RCOG) has guidance on group B Strep infection in newborn babies, which was last updated in September 2017. A national learning published earlier in 2020 by the Healthcare Safety Investigation Branch (HSIB) highlighted that the RCOG guidance was not being followed. This report from the Group B Strep Support reinforces these findings. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Group B Strep Support recommends that the NHS prioritises the prevention of group B Strep infection in newborn babies. A key step towards this would be to ensure published national guidance from recognised expert bodies is adopted and implemented in a timely manner.
  22. News Article
    Maternity staff are facing extreme burnout during the pandemic as staff shortages and longer, busier shift patterns lead to the workforce becoming increasingly overwhelmed, healthcare leaders warned. Senior figures working in pregnancy services told The Independent healthcare professionals are working longer hours, covering extra shifts around the clock, and spending more time on call to compensate for increasing numbers of employees taking time off work after getting coronavirus. Staff say stress-related absences have reached “worryingly” high levels, with junior doctors and midwives “thrown into the deep end” due to having to fill in for colleagues. Professionals argued the coronavirus crisis will lead to a rise in doctors, nurses and midwives suffering post-traumatic stress disorder (PTSD) and other mental health issues – raising concerns staff exhaustion could curb patient safety and standards of care. Read full story Source: The Independent, 31 January 2021
  23. Content Article
    Mothers and families whose baby was born at an NHS hospital after 1st April 2017 and who may be concerned that their baby sustained a brain injury at birth may be going through an investigation process. This guide, from Action Against Medical Accidents (AvMA), provides mothers and families with information about the process.
  24. Content Article
    This BMJ editorial is written by Marian Knight, professor of maternal and child population health and Charlotte Bevan, a bereaved parent. They argue that systems and thinking need to change, and that our healthcare structures are biased against complexity and are not set up to deliver seamless multidisciplinary care. 
  25. News Article
    Two-thirds of women at the heart of a review into maternity services at a Welsh health board could have had very different outcomes if they had received better care, a report has found. The Independent Maternity Services Oversight Panel (Imsop) focused on the experiences of pregnant women at Cwm Taf Morgannwg health board. Its maternity services have been in special measures since "serious failings" were found two years ago. Concerns emerged in late 2018 that women and babies may have come to harm because of staff shortages and failures to report serious incidents. This sparked a major independent review, which gave a damning verdict on maternity services in Cwm Taf Morgannwg health board. Published on Monday, the Imsop report focuses on the care of mothers between January 2016 and September 2018. It found that 19 reviews of maternal care (68%) revealed at least one factor where "different management would reasonably have been expected to alter the outcome". The panel's chairman, Mick Giannasi, said: "These findings will be concerning and potentially distressing for the women and families involved, and it will be difficult for staff." "Of the 28 episodes of care, we concluded that in 27 of them, our independent teams who reviewed the care would have done something differently. Put simply, what went wrong, might not have gone wrong if things had been done differently." Read full story Source: BBC News, 25 January 2021
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