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Found 471 results
  1. News Article
    A trust has been issued with a warning notice after the Care Quality Commission (CQC) raised concerns about parts of its maternity services. Following a focused inspection at University Hospitals Dorset Foundation Trust in September and November last year, the CQC has rated maternity services at Poole Hospital “inadequate”, down from “good”. The service was also rated “inadequate” in the safety and well-led domains. The CQC report warned that Poole Hospital’s maternity unit did not always have enough midwifery or medical staff to keep mothers and babies safe. The inspectors noted this had led to delays to induction of labour and caesarian sections, including emergency sections. A warning notice was also issued over concerns about the unit’s emergency call bell system, which worked “intermittently” due to poor wireless signal, and processes used to summon help during an emergency. The trust said it had since “taken action to address this risk”. Read full story (paywalled) Source: HSJ, 10 March 2023
  2. News Article
    Five women who say they were denied abortions in Texas despite facing life-threatening health risks have sued the state over its abortion ban. Texas bars abortions except for medical emergencies, with doctors facing punishment of up to 99 years in jail. According to the lawsuit, doctors are refusing the procedure even in extreme cases out of fear of prosecution. The Center for Reproductive Justice has filed the legal action on behalf of the five women and two healthcare providers that are also plaintiffs. "It is now dangerous to be pregnant in Texas," said Nancy Northup, the centre's president. One of the women, Amanda Zurawski, said she had become pregnant after 18 months of fertility treatments. She had just entered her second trimester when she was told she had dilated prematurely and that the loss of her foetus, whom she and her husband had named Willow, was "inevitable". "But even though we would, with complete certainty, lose Willow, my doctor could not intervene while her heart was still beating or until I was sick enough for the ethics board at the hospital to consider my life at risk," Ms Zurawski said. For three days, trapped in a "bizarre and avoidable hell", Ms Zurawski was forced to wait until her body entered sepsis - also known as blood poisoning - and doctors were allowed to perform an abortion, according to the lawsuit. Ms Zurawski spent three days in intensive care, leaving the hospital after a week, the legal action says. The ordeal has made it harder for her to conceive in future, she said. Read full story Source: BBC News, 8 March 2023
  3. Content Article
    Risk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
  4. News Article
    When Amy Fantis gave birth to her first child two years ago, the labour was rapid, lasting only about four hours, and she was reliant on gas and air. Her second baby is due in just a few days — but the hospital has, like others around Britain, imposed a ban on the popular form of pain relief. Fantis, 36, from Broxbourne, Hertfordshire, is one of many women affected by the decision of several NHS trusts to suspend the use of the gas because of fears that midwives and doctors have been exposed to unsafe levels for prolonged periods. In some hospitals, levels of the nitrous oxide and oxygen mix are more than 50 times higher than the safe workplace exposure limits. In a survey of more than 16,600 women who gave birth last year, the Care Quality Commission found that 76% of respondents used gas and air at some point during labour. Although short-term use of the gas in childbirth is harmless to women and their babies, long-term exposure for midwives and doctors can affect the body’s ability to absorb vitamin B12, damaging nerves and red blood cells and causing anaemia. It is not believed that any NHS staff have become ill as a result of long-term exposure to gas and air. NHS England and the Health and Safety Executive recently warned other hospitals that they need to check the ventilation on maternity wards and ensure staff are kept safe. NHS England is planning to send out new guidance to trusts on the issue after a series of hospitals had to stop using the gas. Read full story (paywalled) Source: The Times, 25 February 2023
  5. News Article
    Women are being misled and manipulated about abortion by some crisis pregnancy advice centres in the UK, according to evidence from a BBC Panorama investigation. The centres operate outside the NHS and tend to be registered charities. Most say they don't refer women for abortions, but offer support and counselling for unplanned pregnancies. But the BBC's investigation reveals more than a third of these services give misleading medical information or unethical advice, and sometimes both. Pregnancy counselling is available through the NHS and regulated abortion providers, but searching online, Panorama identified 57 crisis pregnancy advice centres advertising. The BBC decided to investigate after hearing from women who had been to these centres. One said she had been "traumatised" and that the centre had tried to "manipulate" her into not having an abortion. Some 21 centres gave misleading medical information and/or unethical advice about abortion Seven centres said having a termination could lead to "post-abortion syndrome" - a mental health condition likened to post traumatic stress disorder, which is not recognised by the NHS. Eight centres linked abortion to infertility and problems carrying future pregnancies to term. Five centres linked abortion to an increased risk of breast cancer. Leading medic in the field of obstetrics, and director of an abortion provider, Dr Jonathan Lord, said women needed an "informed choice" which required "good quality unbiased information". Read full story Source: BBC News, 27 February 2023
  6. Content Article
    The OptiBreech project is a research study exploring the feasibility of evaluating a new care pathway for women with a breech pregnancy. About 1 in 25 babies are born bottom-down (breech) after 37 weeks of pregnancy. Women who wish to plan a vaginal breech birth have asked for more reliable support from an experienced professional. This aligns with national policy to enable maternal choice. In this video, Dr Shawn Walker explains why the combination of meconium and tachycardia, particularly in the first stage of labour, indicates increased risk in breech births.
  7. News Article
    Progress to cut the number of women dying in pregnancy or childbirth has stalled or even reversed in recent years, with a death recorded every two minutes, the United Nations has said. Years of gains had begun to plateau even before the pandemic and there had been “alarming setbacks for women’s health,” according to a new report from several UN agencies, including the World Health Organization (WHO). Maternal mortality rates had fallen widely in the first 15 years of the century, but since 2016, they had only dropped in two UN regions: Australia and New Zealand, and in Central and Southern Asia. The rate went up in Europe and North America by 17% and in Latin America and the Caribbean by 15%. Elsewhere it stagnated. Read full story (paywalled) Source: The Telegraph, 23 February 2023
  8. Content Article
    Every day in 2020, approximately 800 women died from preventable causes related to pregnancy and childbirth - meaning that a woman dies around every two minutes. Sustainable Development Goal (SDG) target 3.1 is to reduce maternal mortality to less than 70 maternal deaths per 100 000 live births by 2030. This report presents internationally comparable global, regional and country-level estimates and trends for maternal mortality between 2000 and 2020.
  9. Content Article
    This Quality Standard from the National Institute for Health and Care Excellence (NICE) has been updated to instruct healthcare professionals to diagnose women under the age of 65 with a urinary tract infection (UTI) if they have two or more key symptoms.
  10. Content Article
    This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies.
  11. News Article
    Rana Abdelkarim died at Gloucestershire Royal Hospital in March 2021 after suffering a bleed post-birth. The Healthcare Safety Investigation Branch (HSIB) found there were delays in calling for specialist help. Her husband, Modar Mohammednour, said that in March 2021 his wife attended the maternity unit at 39 weeks into her pregnancy for what she thought was a routine check-up. Mr Mohammednour said due to language barriers his wife thought she was going "for a scan and to check on her health" and then "come back home", but in fact she was being sent to be induced. "Immediately" after the labour, Ms Abdelkarim suffered heavy bleeding and her condition deteriorated - something Mr Mohammednour said he was "unaware of", until he was eventually called into the hospital to speak to a doctor. According to the investigation by the HSIB, the obstetric team of senior doctors were not told about the drastic change in her condition for almost 30 minutes. An investigation into her death by the HSIB found that once Ms Abdelkarim had been given a drip to speed up labour, regular support from midwives and assessments could not be given to her because the maternity ward was so busy. It also found there was a 53-minute delay from the point of bleeding to administering the first blood transfusion. HSIB also found Ms Abdelkarim was "uninformed" about the reason for her admission, "consent to induce labour was not given" and because she was thin and small, staff underestimated how much relative blood volume she was losing. Read full story Source: BBC News, 7 February 2023
  12. News Article
    Hepatitis B transmission from mothers to babies has been eliminated in England, according to the World Health Organisation (WHO). The WHO elimination target is that less than 2% of babies born to mothers with hepatitis B go on to develop the infection. And data from the UK Health Security Agency (UKHSA) shows the figure for England currently stands at 0.1% The UKHSA said progress had been made in tackling the viral infection, which can cause liver damage, cancer and death if left untreated. A six-in-one vaccine is offered to all babies on the NHS when they are eight, 12 and 16 weeks of age. Health and Social Care Secretary Steve Barclay said: “We are paving the way for the elimination of hepatitis B and C, with England set to be one of the first countries in the world to wipe out these viruses.” Read full story Source: The Independent, 2 February 2023 .
  13. News Article
    The UK is facing a “crisis point” in abortion provision, experts say, with rising demand and restricted access to care in many areas putting unprecedented pressure on struggling NHS services. Healthcare professionals described a “terrifying” state of affairs in which women are travelling hundreds of miles for appointments or waiting several weeks before they are seen. Dr Jonathan Lord, the director of MSI Reproductive Choices UK, a major provider of abortion services, told the Guardian’s Today in Focus podcast: “There is no doubt we are seeing absolutely unprecedented levels of demand at the moment. All providers are reporting they are busier than they have ever been.” Lord, who is also an NHS consultant gynaecologist, said the rise was being driven by “the economic downturn, the cost of living crisis and the ability to access good quality contraception” via GPs and sexual health services, which have been affected by the wider NHS crisis. Clare Murphy, the chief executive at the British Pregnancy Advisory Service (BPAS), previously said: “The pandemic, and the policies adopted by the government, have had a clear impact on women’s pregnancy choices.” Faced with “economic uncertainty and job insecurity”, women had been forced to make tough decisions, she said. Read full story Source: The Guardian, 26 January 2023
  14. Content Article
    The Health and Social Care Select Committee have published a new report reviewing the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. This blog sets out Patient Safety Learning’s reflections on this report.
  15. Content Article
    This Health and Social Care Select Committee report reviews the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. You can read Patient Safety Learning’s reflections on this report here.
  16. News Article
    Fewer women who gave birth in NHS maternity services last year had a positive experience of care compared to 5 years ago, according to a major new survey. The Care Quality Commission’s (CQC) latest national maternity survey report reveals what almost 21,000 women who gave birth in February 2022 felt about the care they received while pregnant, during labour and delivery, and once at home in the weeks following the arrival of their baby. The findings show that while experiences of maternity care at a national level were positive overall for the majority of women, they have deteriorated in the last 5 years. In particular, there was a notable decline in the number of women able to get help from staff when they needed it. Many of the key findings from the survey include a drop in positive interactions with staff and lack of choices about the birth. Just over two-thirds of those surveyed (69%) reported 'definitely' having confidence and trust in the staff delivering their antenatal care. Results were higher for staff involved in labour and birth (78%). In addition, while the majority of women (86%) surveyed in 2022 said they were 'always' spoken to in a way they could understand during labour and birth, this was a decline from 90% who said this in 2019. The proportion of respondents who felt that they were 'always' treated with kindness and understanding while in hospital after the birth of their baby remained relatively high at 71%, however had fallen from 74% in 2017. Just under a fifth of women who responded to the survey (19%) said they were not offered any choices about where to have their baby. Also, less than half (41%) of those surveyed said their partner or someone else close to them was able to stay with them as much as they wanted during their stay in hospital. Read full story Source: Medscape, 13 January 2023
  17. Content Article
    This survey from the Care Quality Commission (CQC) looked at the experiences of women and other pregnant people who had a live birth in early 2022.
  18. Content Article
    Recording of the Health and Social Care Committee meeting held on Tuesday 13 December 2022. Meeting started at 10.03am, ended 11.45am.
  19. Content Article
    This policy paper, published by the Department of Health and Social Care, provides an update on the UK Government’s progress in implementing the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
  20. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
  21. News Article
    The rising number of women who have caesarean sections instead of natural births is causing concern for the National Childbirth Trust (NCT). The trust, which supports women through pregnancy, childbirth and early parenthood, says it does not know why the rate of caesareans is increasing. One in four maternity services showed a caesarean rate of between 20% and 29.9%, and 2% of services had a rate of more than 30%, according to latest figures. The World Health Organization recommends that the acceptable rate is 10 to 15%. The maternity care working party, a multi-disciplinary group set up by the NCT, said there was an urgent need to address the problem. "A caesarean is major abdominal surgery," the working party said in a statement to a conference in London with the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists "Most women would prefer to give birth normally, provided that a normal birth is considered safe for them and their baby. It is important that health professionals' advice does not have the effect of denying them this opportunity without good reason." The working party is calling for data to be published on caesarean section rates and for obstetricians to justify in each case that the benefits outweigh the hazards. It also wants action to be taken to prevent any inappropriate use of caesarean sections. Belinda Phipps, chief executive of the NCT, said: "We know that in many cases caesareans are necessary for good clinical reasons. However, in our view rates have reached unacceptable levels and we want to know why." Read full story Source: The Guardian, 24 November 2022
  22. News Article
    Mothers are being offered water injections by the NHS to relieve pain during childbirth, while in some hospitals midwives are burning herbs to encourage breech babies to turn in the womb. Safety campaigners have dubbed the practices dangerous and say that they amount to “pseudoscience” being offered by the health service. They have called on the chief executive of NHS England, Amanda Pritchard, to ban their use in a letter published over the weekend. At least three trusts in England offer water injections for pain relief, including Newcastle upon Tyne Hospitals Trust, United Lincolnshire Hospitals Trust and North Tees and Hartlepool Trust. Information on the Newcastle trust’s website describes the injections as an “alternative form of pain relief” while in Lincolnshire patients are told the body’s response to the injections “prevents pain signals from reaching the brain.” The National Institute for Health and Care Excellence (NICE), which is responsible for setting out which treatments patients should receive, has said the NHS should not use injected water for pain relief. Read full story (paywalled) Source: The Times, 27 November 2022
  23. News Article
    A maternity unit criticised for the preventable stillbirth of a baby is under investigation after the unexpected death of a second baby. The newborn baby died in December last year after her birth at the standalone midwifery-led unit (MLU) at Lagan Valley Hospital in Lisburn. Despite this, the unit continued to operate as normal for another three months when the South Eastern Trust temporarily paused births at the MLU. The second tragedy came four years after Jaxon McVey was stillborn when his delivery at the unit went catastrophically wrong. A post-mortem found he died as a result of shoulder dystocia – an obstetric emergency where the head is born but the shoulder becomes trapped behind the pubic bone. Jaxon’s mum, Christine McCleery, has hit out at the South Eastern Trust and raised concerns over the measures put in place following his stillbirth on Mother’s Day 2017. “I feel like they didn’t learn from Jaxon,” she said. “I don’t know if any other babies died before Jaxon, but I know one died afterwards. Read full story (paywalled) Source: The Independent, 23 November 2022
  24. News Article
    Contrary to current advice, getting pregnant within a few months of an abortion or a miscarriage does not appear to be extra risky for the mum and baby, say researchers who have looked at recent real-life data. The World Health Organization (WHO) recommends at least a six-month gap to give the woman time to recover. However, a study in PLoS Medicine, analysing 72,000 conceptions, suggests couples might safely try sooner for a baby. The baby loss support charity Tommy's says women who feel ready to try again immediately after a miscarriage should do so if there is no medical reason against it. The WHO says more research into pregnancy spacing is already under way and would inform any future updates to the advice. The research from Norway, spanning eight years from 2008 to 2016, found no major differences in outcomes when a new pregnancy happened sooner than a six-month delay. That is a different finding to earlier work in Latin America that - along with other studies - informed the WHO recommendations on pregnancy spacing. The authors of the latest Norwegian analysis say the advice needs reviewing so that couples can make an informed decision about when to try for a baby. Read full story Source: BBC News, 23 November 2022
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