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.
The report sets out seven themes identified by the review and charts the safety risks for pregnant women that emerged as the NHS adapted to respond to COVID-19. It describes the circumstances and pathways of care for the 19 women where some of the risks identified in the theme areas may have contributed to the outcome for those women.
The review also highlighted that the ‘system factors’ identified in the maternal reviews were seen across the NHS and have been or are being addressed in other HSIB investigations. The seven themes are:
- Unprecedented demand for telephone health advice caused delays in accessing healthcare.
- Public messaging and safety netting advice caused delays in presentation.
- Guidance changed rapidly.
- Use of early warning scores did not always detect deterioration.
- Personal protective equipment requirements changed due to COVID-19.
- Staff described feelings of stress and distress which can affect performance.
- Difficulties in making a diagnosis and choosing treatment strategies – the difficulties were in the context of clinicians tackling an unknown virus that they had to learn about as it progressed.
HSIB makes the following safety observations:
- It may be beneficial if further work is done to understand the increased risk of maternal death for women from Black, Asian and minority ethnic backgrounds and those with higher socio-economic deprivation.
- It may be beneficial if the NHS England and NHS Improvement communications toolkit for local maternity teams to improve communications with women from Black, Asian and minority ethnic backgrounds is implemented in all healthcare services for pregnant women.
- It may be beneficial if written safety netting advice is developed for pregnant and postpartum women about COVID-19 and other common conditions, incorporating the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) recommendations.