National learning report: Factors affecting the delivery of safe care in midwifery units (Maternity & Newborn Safety Investigations programme, 8 May 2024)

Summary

This 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.

Content

Analysing 92 investigations completed on or before 14 June 2022, the report identifies the following four common themes as issues impacting on maternity safety:

• Work demands and capacity to respond – the number of tasks needed to be done and whether there are enough (and suitable) staff, and appropriate physical space, to do them.
• Intermittent auscultation – a method used to assess a baby’s heart rate as an indicator of their wellbeing.
• How prepared an organisation is for predictable safety-critical scenarios, and the role played by in situ simulation (a training method that involves staff rehearsing scenarios in the workplace).
• Telephone triage – the assessment a midwife carries out when a pregnant woman telephones because they have gone into labour or have a concern about their pregnancy.