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  • HSIB: Delays to intrapartum intervention once fetal compromise is suspected (November 2020)

    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • Healthcare Safety Investigation Branch
    • 12/11/20
    • Health and care staff, Patient safety leads


    Identifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report.

    The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor.

    The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk. 


    As a result of the investigation, one recommendation has been made to the Care Quality Commission (CQC) on assessing factors such teamwork and psychological safety in its regulation of maternity units. Based on the evidence gathered, the report also sets out a series of questions to consider in order to help staff identify strengths and opportunities for improvement within their own maternity unit.

    Safety recommendation

    • It is recommended that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary teamwork and psychological safety in its regulation of maternity units. 

    Questions to consider

    • Does your unit have a role, or another means, separate from the labour ward co-ordinator, dedicated to monitoring and anticipation of activity across the maternity service and troubleshooting, such as a roving bleep holder?
    • Do you have regular multidisciplinary ward rounds throughout the day?
    • Do you have regular safety huddles and multidisciplinary handovers using a structured information tool?
    • Do you hold multidisciplinary in situ simulation and facilitated debriefing that includes both technical and non-technical skills? Are scenarios and incidents encountered in your unit included in the training?
    • Do you know what your staff’s perceptions of teamwork, psychological safety and communication are within your unit? Are actions taken in response? How are midwifery staff empowered to contact consultants directly if they have concerns?
    • Is time and resource dedicated to regular multidisciplinary forums that provide a safe space to openly discuss scenarios where things did not go well? Do these forums also include discussion and reflection on scenarios where things went well despite unexpected events? 
    • Are senior midwifery staff assigned to triage and assessment areas? Is there adequate medical presence in these areas?
    • In larger units, is the workload on the labour ward separated into elective and emergency work? If so, are there separate labour ward co-ordinators for each?
    • How does the physical infrastructure support work? For example, use of DECT telephones, availability of equipment, consultant offices on/near the labour ward, proximity of antenatal ward and neonatal unit to the labour ward.
    • How are issues with staffing and workload escalated and responded to? Are senior trust personnel aware and involved?
    HSIB: Delays to intrapartum intervention once fetal compromise is suspected (November 2020) https://www.hsib.org.uk/documents/261/HSIB_Delays_to_intrapartum_intervention_once_fetal_compromise_is_suspected_Report.pdf
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