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Content Article
Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. Early recognition and treatment have been shown to significantly improve babies' chances of making a full recovery. In the second blog of this series, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, shares Kit’s story, who died at just 13 days old. Sarah reflects on a number of ‘missed signs’, highlighting the urgent need for increased awareness among staff.- Posted
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News Article
Third of services rated ‘red’ for baby deaths
Patient Safety Learning posted a news article in News
The proportion of trusts with maternity services “red rated” for neonatal mortality rose from around a quarter in 2021 to a third in 2022, according to the latest national audit. The latest Mothers and Babies: Reducing Risk Through Audit and Confidential Enquiries report, published on Friday, classifies trusts from red to green, according to how far above or below they are their peer group providers. Nationally, there were increases in the neonatal mortality rate per 1,000 live births in 2022 compared with 2021, rising from 1.65 to 1.69 per 1,000 total births. Neonatal death is when a baby dies in the first 28 days of life. Of 121 trusts, 41 (34%) were rated “red” for neonatal mortality in 2022, as their rates were over 5% higher than their peer group average. This compares with 32 trusts (26% of 123 trusts) rated “red” for neonatal mortality in 2021. There were, however, also some areas of improvement year-on-year. The number of trusts rated “green” — with neonatal death rates more than 15% lower than the average in their peer group — increased from three in 2021 to eight in 2022, marking a significant improvement from 2020 and 2021. Read full story (paywalled) Source: HSJ, 17 July 2024 -
Content ArticleThis is the tenth MBRRACE-UK Perinatal Mortality Surveillance Report. The report is divided into five sections: perinatal mortality rates in the UK; mortality rates for Trusts and Health Boards; mortality rates by gestational age; mortality rates by ethnicity and socio-economic deprivation; and a description of the causes of perinatal death. This report focuses on births from 24 completed weeks’ gestational age, with the exception of the section on mortality rates by gestational age, which also includes information on births at 22 to 23 completed weeks’ gestational age. This avoids the influence of the wide disparity in the classification of babies born before 24 completed weeks’ gestational age as a neonatal death or a late fetal loss. Terminations of pregnancy have been excluded from the mortality rates reported. Additional supporting materials to accompany this report include: a set of reference tables a data viewer with interactive mapping, which presents mortality rates for individual organisations, including Trusts and Health Boards a technical manual containing full details of the MBRRACE-UK methodology, including definitions, case ascertainment and statistical methods.
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News Article
Bug-spread baby deaths 'could have been prevented'
Patient Safety Learning posted a news article in News
Two babies died on a hospital’s neonatal intensive care unit during a bacterial outbreak which could have been prevented, the BBC has learned. An internal investigation by Bradford Royal Infirmary (BRI) said lapses in hygiene practices allowed the drug-resistant bugs to spread. Five other infants were found to have the same Klebsiella pneumoniae strain during the outbreak in November 2021. The mother of a two-week-old boy who died said she felt “betrayed” by the hospital and had begun legal action. Bradford Teaching Hospitals NHS Trust said it had implemented new infection control measures, brought in additional training and increased staffing levels. A nurse who previously worked at the neonatal unit told the BBC staff faced “extremely strenuous” conditions which led to “medical mistakes”. A patient safety incident investigation report, circulated internally in March 2022 and seen by the BBC, also said infection control practices which could have stopped the spread of Klebsiella “were not being implemented consistently” by staff in the unit. It revealed an investigation had found staff in the neonatal unit were not “consistently” following hand hygiene guidelines at the time of the outbreak and “seemed unclear” about where and when personal protective equipment was required. Read full story Source: BBC News, 16 July 2024 -
News Article
Lucy Letby sentenced to 15th whole life term
Patient Safety Learning posted a news article in News
Former nurse Lucy Letby has been sentenced to another whole life term for trying to kill a premature baby girl. The 34-year-old is already in jail for murdering seven babies and attempting to murder six others at the Countess of Chester Hospital between June 2015 and June 2016. On Tuesday, she was found guilty of trying to murder another girl, known as Baby K, following a retrial. Letby had refused to go up to the dock to be sentenced to 14 whole life terms last August, but was in the dock earlier to be handed her 15th. Her original murder trial jury acquitted her of two counts of attempted murder, and there were six further charges on which jurors could not decide, including that concerning Baby K. Read full story Source: BBC News, 5 July 2024 -
Content Article
Top picks: 6 resources about Group B Strep
Patient Safety Learning posted an article in Maternity
Knowing about Group B Strep when you’re pregnant or in the early weeks after birth can make a massive difference – most Group B Strep infections in newborn babies can be prevented, and early treatment can and does save lives. Group B Strep Awareness Month focuses on empowering new and expectant parents with the knowledge they need to make informed decisions about their baby and engaging with healthcare professionals to improve education and awareness. In this blog, Patient Safety Learning has pulled together six useful resources about Group Strep B shared on the hub. -
News ArticleThe NHS will face scrutiny over alleged failures to listen to whistleblowers’ warnings about baby killer Lucy Letby after the nurse was convicted of another attempted murder. Letby was convicted of trying to murder a “very premature” infant by dislodging her breathing tube in the early hours of 17 February 2016, following a retrial at Manchester Crown Court. The 34 year-old’s latest conviction comes after she was found guilty of the murders of seven babies and the attempted murders of six others at the Countess of Chester Hospital’s neo-natal unit between June 2015 and June 2016, following her original trial last August. The former nurse was given a rare whole-life order, making her one of Britain’s most prolific child serial killers. She is due to be sentenced for the further offence on Friday. Detective superintendent Simon Blackwell, who is strategic lead for Operation Hummingbird, said: “The investigation, which is ongoing, focuses on the indictment period of the charges for Lucy Letby, from June 2015 to June 2016, and is considering areas including senior leadership and decision making to determine whether any criminality has taken place. The investigation is complex and sensitive and specific updates regarding progress will be issued at the appropriate time. At this stage we are not investigating any individuals in relation to gross negligence manslaughter. “We recognise that this investigation has a significant impact on a number of different stakeholders including the families in this case and we want to reassure that we are committed to carrying out a thorough investigation. Since Letby’s original convictions in August 2023 it has been a very busy period for the investigation team. This has included a subsequent appeal, the re-trial for one count of attempted murder and the launch of the statutory public inquiry that Cheshire Constabulary is assisting with.” Read full story Source: The Independent, 2 July 2024
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News Article
Hacked UK trove includes data on newborns, cancer patients...
Patient Safety Learning posted a news article in News
Hackers behind a London hospital attack recently published records that include personal information about pregnant women, newborns, cancer patients, people suffering from schizophrenia and thousands of others across the UK and Ireland, revealing the breach was far more widespread than authorities have previously indicated. An analysis of the data trove by Bloomberg News found that it contains tens of thousands of medical records on patients from more than 400 public and private hospitals and clinics. Among the records are some 40,000 highly sensitive documents sent by doctors requesting biopsies and blood tests for individual patients in all regions of the UK and some hospitals in Ireland. A breach of the kind faced by Synnovis was inevitable, according to Saif Abed, a former NHS doctor and expert in cybersecurity and public health. “The NHS has some of best patient safety and cybersecurity standards in the world,” Abed said. “They are just immensely poorly enforced.” Abed said that there was a lack of mandatory cybersecurity audits on any contractors providing services to the NHS, which meant those contractors could have substandard cybersecurity practices that could in turn leave the NHS vulnerable. Read full story Source: Bloomberg UK, 26 June 2024 -
Content Article
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Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). In this blog, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, draws on her own devastating experience of her son dying to illustrate why healthcare staff with cold sores must stay away from new babies. Sarah highlights the lack of awareness of the dangers and calls for a widespread review of policy in order to prevent future deaths. -
News Article
C2-Ai launches Maternal and Neonatal Observatory
Clive Flashman posted a news article in News
C2.AI has formally launched its Maternity and Neonatal Observatory at the NHS ConfedExpo in Manchester (Government and Public Sector Journal). The observatory is intended to give hospitals and clinicians a detailed picture of the performance of maternity units and the health trajectories of individual women, so areas of concern can be identified and acted on. The system works by calculating and comparing observed outcomes for women and babies with expected outcomes for these individuals. To do this, it uses AI and machine learning to assess clinical factors, case-mix, and the social determinants of health. Early adopters within the NHS, where maternity services are under intense scrutiny, are expected soon. -
Content ArticleTotal parenteral nutrition (TPN, also known as PN) is a method of providing nutrition directly into the bloodstream to those unable to absorb nutrients from the food they eat. TPN is used in all age groups, but in babies its use is often as part of a temporary planned programme of nutrition to supplement milk feeds in those too immature to suckle or too sick to receive milk feeds as a result of intestinal conditions. TPN consists of both aqueous and lipid components, which are infused separately into the baby via specific administration sets and infusion pumps. The rate at which TPN is administered to a baby is crucial: if infused too fast there is a risk of fluid overload, potentially leading to coagulopathy, liver damage and impaired pulmonary function as a result of fat overload syndrome. In a recent three and a half year period 10 incidents were identified where infusion of the aqueous and/or lipid component of TPN at the incorrect rate resulted in severe harm to babies through pulmonary collapse, intraventricular haemorrhage or organ damage, and where intensive intervention and treatment were needed. Most of these incidents involved too rapid a rate of infusion.
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News Article
Parents hope documentary will help maternity inquiry bid
Patient Safety Learning posted a news article in News
A couple whose child died before birth due to failings in her care hope a new documentary can support their calls for a public inquiry into England's maternity services. Jack and Sarah Hawkins' daughter Harriet was stillborn at Nottingham City Hospital in April 2016. They hope an ITV programme - Maternity: Broken Trust - shown on Sunday evening can help their bid for a wider probe. An independent review into failings in maternity services in Nottingham is now the biggest maternity investigation in NHS history, but a report is not expected to be returned until 2025. Dr and Ms Hawkins - who received a £2.8m settlement over failings in their daughter's care - said a wider investigation was needed to highlight national issues. "I think maternity services across England are absolutely terrible," Ms Hawkins said. "We're in contact with people with dead babies from Leeds to Plymouth, and I think what really needs to happen is for there to be a public inquiry into England's maternity services. "It's not just Nottingham, it's everywhere, and hopefully this platform will give people the strength to come forward and speak up." Read full story Source: BBC News, 10 June 2024 -
News Article
Three more babies die after developing whooping cough, says UKHSA
Patient Safety Learning posted a news article in News
Three more babies have died from whooping cough this year as cases continue to rise across the country, according to the UK Health Security Agency. Since January, there have been 4,793 confirmed cases of whooping cough, with 181 babies under the age of three months diagnosed with the illness. A total of eight babies have now died from whooping cough this year. Pregnant women have been urged to get the whooping cough vaccine in order for their babies to be protected before they are old enough to receive the vaccine themselves. Babies can first be vaccinated against the disease when eight weeks old, while pregnant women are advised to get the vaccine at 16 and 32 weeks. Dr Gayatri Amirthalingam, a consultant epidemiologist at UKHSA, said: “Our thoughts and condolences are with those families who have so tragically lost their baby. “With whooping cough case numbers across the country continuing to rise and sadly the further infant deaths in April, we are again reminded how severe the illness can be for very young babies. “Pregnant women should have a whooping cough vaccine in every pregnancy, normally around the time of their mid-pregnancy scan (usually 20 weeks). This passes protection to their baby in the womb so that they are protected from birth in the first months of their life when they are most vulnerable and before they can receive their own vaccines. “The vaccine is crucial for pregnant women, to protect their babies from what can be a devastating illness.” Read full story Source: The Guardian, 6 June 2024 -
News Article
Trust suspends treatment for premature babies after several deaths
Patient-Safety-Learning posted a news article in News
A national study is examining whether a treatment for premature babies could cause harm, amid concerns about the deaths of four infants last year, it has emerged. HSJ has learned a national study into the use of prophylactic low-dose hydrocortisone steroids, also known as “premiloc”, is being carried out at the Neonatal Data Analysis Unit, part of the Imperial College London Medical School. Meanwhile, University College London Hospitals Foundation Trust confirmed that four children died in January and February 2023 last year, having been transferred from UCLH to nearby Great Ormond Street Hospital, after receiving the treatment. They had been given hydrocortisone steroids at UCLH to reduce the risk of developing a lung condition called bronchopulmonary dysplasia. UCLH said its own internal investigations “did not confirm a direct link” between the deaths and the drug, “but concern remained” so they were reported to the regional neonatal network. UCLH noted that the national study at Imperial was now under way, although the Imperial team told HSJ it was not specifically aware of the UCLH/GOSH deaths last year. A report from GOSH’s safety team last year, seen by HSJ, said: “In all four deaths the mortality review group identified modifiable/potential modifiable factors around the administration of premiloc prior to admission to GOSH. Administration of premiloc (hydrocortisone steroids) to these babies may have been associated with the subsequent perforations. A series of incidents of perforations was flagged to the UCLH neonatal unit who reviewed data and have stopped the administration of premiloc.” Read full story (paywalled) Source: HSJ, 5 June 2024 -
News Article
Parents call for inquiry into maternity services
Patient Safety Learning posted a news article in News
The families of nine babies who died at a scandal-hit NHS trust over a three-year period have called for a public inquiry into the standard of its maternity care. A collective letter has been sent to each of the families' MPs after they lost babies at hospitals run by the University Hospitals Sussex NHS Foundation Trust. Of the nine bereaved mothers, four said they too almost died as a result of "poor standards of care" from maternity teams between 2021 and 2023 The trust said it had recruited more midwives and "changed" how it supported families, with outcomes now better "than most other trusts in the country". But the Sussex-based families said they had called for a public inquiry into its maternity services to ensure accountability for "systemic failures", and so the trust learns from past mistakes. In the letter to the MPs, the parents said: "With the volume and repetition of errors in maternity care by the trust, we believe that babies and potentially mothers will continue to unnecessarily die under the trust’s care unless there is additional intervention." Read full story Source: BBC News, 4 June 2024 -
Content ArticleThis cohort study in JAMA Network Open aimed to determine whether US Food and Drug Administration (FDA) warnings to prevent prenatal exposure to valproic acid are associated with changes in pregnancy risk and contraceptive use. The study examined 165 772 valproic acid treatment episodes among 69 390 women and found that pregnancy rates during treatment remained unchanged during the 15-year study, and were more than doubled among users with mood disorder or migraine compared with epilepsy. Contraception use among users was uncommon, with only 22.3% of treatment episodes having a 1-day overlap of valproic acid and contraception use. The authors argue that these findings suggest a need to review efforts to prevent prenatal exposure to valproic acid, especially for clinical indications where risk of use during pregnancy outweighs therapeutic benefit and safer alternatives are available.
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News Article
Local control of NHS screening could jeopardise patient safety
Patient-Safety-Learning posted a news article in News
Patients could be put at risk by plans to allow local NHS bodies to oversee the quality of health screening programmes for diseases such as breast and bowel cancer, experts have suggested. At the moment, NHS England runs the Screening Quality Assurance Service (SQAS) to make sure local organisations comply with national standards, are safe and can be subject to inspections. There are 11 national screening programmes in England, including those for breast, cervical and bowel cancer, plus antenatal and newborn screening, abdominal aortic aneurysm and diabetic eye screening. At the moment, screening programmes must report all safety incidents to the SQAS and the SQAS inspectors visit local sites to pick up urgent issues and make recommendations. Now, a report in the British Medical Journal questions plans by NHS England to allow local bodies to have more control. Sue Cohen, former national lead of screening quality assurance at Public Health England, told the BMJ that devolving responsibility for SQAS to local organisations would be a “retrograde” step. She pointed to previous issues, such as in Kent where a lack of oversight of a cervical screening programme led to women with cancer not being picked up. She said: “If you don’t have a quality assurance service that is properly resourced and has that ability to keep a national view, you will simply not have the oversight of the system and there is a bigger risk of incidents going undetected.” Read full story Source: Medscape News, 22 May 2024 -
Content ArticleThe Thirlwall Inquiry is examining events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. As part of this Inquiry, its Terms of Reference asks: “Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?”. To help inform its work in this area, the Inquiry Legal Team has produced this Table of Inquiries and reviews which have been conducted in England and Wales over the last thirty years. Recommendations from each Inquiry have been set out in a comprehensive table, alongside details of whether or not those recommendations have been implemented.
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Content Article
Saving Babies’ Lives 2024: A report on progress (May 2024)
Patient-Safety-Learning posted an article in Maternity
This is the second ‘saving babies’ lives’ progress report from the Joint Policy Unit. When the first report was published in May 2023, the Unit committed to reassessing progress each year. Through this process it aims to hold government and decisionmakers to account, helping to ensure that saving babies’ lives and tackling inequalities in pregnancy and baby loss are the political priorities they deserve to be. This years report highlights that maternity services need a much more transformative approach from government, that matches the scale and impact of the issue. Maternity services are not on course to meet government ambitions to reduce rates of stillbirth, neonatal death or preterm birth, and there continue to be stark and persistent inequalities in rates of pregnancy and baby loss by ethnicity and deprivation. View a summary version of the report -
Content Article
On 9 January 2024, the All-Party Parliamentary Group (APPG) on Birth Trauma established the first national inquiry in the UK Parliament to investigate the reasons for birth trauma and to develop policy recommendations to reduce the rate of birth trauma. Seven oral evidence sessions took place on consecutive Mondays between 5 February and 18 March 2024 in the House of Commons. The Inquiry was also informed by written submissions which were received following a public call for evidence. The inquiry received more than 1,300 submissions from people who had experienced traumatic birth, as well as nearly 100 submissions from maternity professionals. It also held seven evidence sessions, in which it heard testimony from both parents and experts, including maternity professionals and academics. -
News Article
Whooping cough: Cases up again as five infant deaths reported
Patient-Safety-Learning posted a news article in News
Five babies have died from whooping cough as cases continue to rise in England, health officials have announced. The UK Health Security Agency (UKHSA) reported 1,319 cases in England in March, after just over 900 in February, making the 2024 total nearly 2,800. It fears it could be a bumper year for the bacterial infection. The last peak year, 2016, saw 5,949 cases in England. The infection can be particularly serious for babies and infants. Half of cases seen so far this year have been in the under-15s, with the highest rates in babies under three months of age. The five babies who died this year were all under three months old. Known as pertussis or "100-day cough", the infection is a cyclical disease with peaks seen every three to five years. UKHSA has said a steady decline in uptake of the vaccine in pregnant women and children and the very low numbers seen during the pandemic, as happened with other infections because of restrictions and public behaviour, were both factors. The agency said a peak year was therefore overdue and urged families to come forward to get vaccinated if they had not already. Read full story Source: BBC News, 9 May 2024 -
Content ArticleThis report by the Maternity & Newborn Safety Investigations (MNSI) programme examines findings from 92 of their investigations where safety recommendations were made to midwife-led units in NHS hospital trusts in England. It highlights key learnings and prompts to help trusts to consider how safety risks can be mitigated and drive improvements in care.
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News ArticleNHS staff do not correctly monitor a baby’s heart rate during labour in almost half of cases where serious failings lead to tragedy, a review of maternity care has found. The Care Quality Commission identified that inadequate foetal monitoring occurred in 45 of 92 cases (49%) in which a baby died or suffered serious brain damage while being born in a midwife-led unit in England. The findings show that correct monitoring is “critically important” to ensure care is safe in all maternity units, said Sandy Lewis, the director of the CQC’s maternity and newborn safety investigations (MNSI) programme. It analysed four common failings in the 92 births in a report that is intended to help midwives and doctors improve the quality and safety of care. In one case the investigation team found that “there were likely to have been abnormalities in the baby’s heart rate which were ongoing for a prolonged period of time, which were not identified during intermittent auscultation [monitoring]”. In another, midwives were so busy dealing with a separate emergency on the unit that they failed to monitor the baby at the correct recommended intervals and the woman was left unattended. The 92 incidents involved 62 cases in which the newborn suffered a severe brain injury, 19 in which it was alive at the start of labour but was stillborn and 11 when it died within its first six days of life. Read full story Source: Guardian, 8 May 2024
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News ArticleAn inquest into the death of a baby boy who died two weeks after birth in a Sussex hospital has found there were missed opportunities in the care of his mother. Orlando Davis was born by emergency caesarian section at Worthing Hospital, part of University Hospitals Sussex NHS Foundation Trust, on 10 September 2021 following a normal and low risk pregnancy. He was born with no heartbeat and his parents were told he had suffered an irreversible brain injury after being starved of oxygen - after his mother Robyn Davis experienced seizures during labour, caused by a rare condition that went "completely unrecognised" by staff. Orlando died in Robyn and husband Jonny’s arms on 24 September 2021 at 14 days old due to his catastrophic brain injury. His mother had to be put in an induced coma, but has since recovered. But his parents say his death was avoidable. Today at the inquest into Orlando's death, senior coroner, Ms Penelope Schofield said a lack of understanding of hyponatremia contributed to neglect of Orlando. Mrs Davis had told the inquest: “I can’t explain the sadness, frustration, anger and complete heartbreak I felt and still feel towards the trust for not keeping us safe. Mrs Davis continued: “The thing I cannot process is that I have lost my healthy, full-term son. I feel as if my son was taken from me in a circumstance that, in my personal and professional opinion, was completely preventable. Read full story Source: ITVX, 14 March 2024
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Content ArticleNeonatal herpes simplex virus (HSV) disease is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. Early recognition and treatment of the virus has been shown to significantly improve babies' chances of making a full recovery. Kit Tarka Foundation works to prevent newborn baby deaths; primarily through raising awareness of neonatal herpes, funding research and providing advice for healthcare professionals and the general public.
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