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  • HSIB: Maternity pre-arrival instructions by 999 call handlers (17 February 2022)


    Mark Hughes
    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • Healthcare Safety Investigation Branch
    • 17/02/22
    • Everyone

    Summary

    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to help improve patient safety in relation to the instructions 999 call handlers give to women and pregnant people who are waiting for an ambulance because of an emergency during their pregnancy.

    The HSIB investigation reviewed the case of Amy, who was 39 weeks and 4 days pregnant with her first child. She contacted 999 after experiencing abdominal cramps and bleeding. While waiting for an ambulance to arrive, Amy received pre-arrival instructions which were generated through a clinical decision support system (CDSS) from a non-clinical call handler. Amy was then taken by ambulance to hospital where her baby, Benjamin, was delivered by emergency caesarean section.

    Amy had excessive blood loss due to a placental abruption and was admitted to the high dependency unit for 12 hours following the birth. Benjamin required resuscitation to help him breathe on his own, he was intubated, and he received 72 hours of therapeutic cooling. He spent 13 days in hospital.

    Content

    Initial maternity investigation

    Amy’s case formed one part of an initial investigation carried out by the HSIB maternity investigation programme. This investigation identified a potential patient safety risk regarding the pre-arrival instructions given to women/pregnant people by 999 call handlers while they wait for an ambulance. Aspects of the pre-arrival instructions did not align with UK evidence-based maternity guidance (for clinicians in a clinical setting). This was considered to present a risk of harm to women or pregnant people and/or babies.

    Similar concerns relating to maternity pre-arrival instructions given by 999 call handlers were identified in 15 HSIB maternity investigations. These were referred to HSIB’s national investigation programme for consideration for a national investigation.

    Findings

    Findings of this investigation included:

    • There are two triage clinical decision support systems in use in England, which provide different pre-arrival instructions for the same maternity clinical scenario for women/pregnant people who are waiting for an ambulance to arrive.
    • The different pre-arrival instructions across triage clinical decision support systems, for the same reported symptoms, have different clinical implications/risks, creating a ‘postcode lottery’ of care.
    • Stakeholders acknowledged a gap in maternity emergency guidance relating to the non-visual, non-clinician-attended environment.
    • The investigation found no evidence of a regulatory mechanism for 999 call handler pre-arrival instructions.

    Recommendations

    The report makes the following safety recommendations:

    • HSIB recommends that the Department of Health and Social Care commissions the National Institute for Health and Care Excellence to work with relevant stakeholders to develop guidance for maternity emergencies in the non-visual, non-clinician-attended environment.
    • HSIB recommends that the Department of Health and Social Care identifies a suitable regulatory mechanism to provide formal oversight of 999 maternity pre-arrival instructions across NHS-funded care in England.
    • HSIB recommends that NHS England and NHS Improvement develops the content of the patient safety incident investigation (PSII) standards to further support cross-boundary investigations.
    HSIB: Maternity pre-arrival instructions by 999 call handlers (17 February 2022) https://www.hssib.org.uk/patient-safety-investigations/maternity-pre-arrival-instructions-by-999-call-handlers/
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