HSIB National Learning Report. Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic, 1 April to 30 June 2020

Summary

The number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year.

The data initiated a HSIB national learning report, which explores the findings from their maternity investigations during this time. They investigated intrapartum (labour) stillbirths after 37 weeks, where a baby was thought to be alive at the start of labour and was born with no signs of life.

Content

Safety recommendations

HSIB made eight safety recommendations as a result of this investigation, five to NHS England and NHS Improvement, one to the Royal College of Obstetricians and Gynaecologists, one to NHSX, and one to DHSC.

1. HSIB recommends that future iterations of the Royal College of Obstetricians and Gynaecologists’ guidance clarify the management of a reported change in fetal movements during the third trimester of pregnancy with due regard to national policy.
2. HSIB recommends that NHS England and NHS Improvement leads work to develop a process to ensure consistency and clarity across national maternity clinical guidance.
3. HSIB recommends that NHS England and NHS Improvement leads work to collate and act on the evidence on the risks and benefits associated with the use of remote consultations at critical points in the maternity care pathway.
4. HSIB recommends that the Department of Health and Social Care commission a review to improve the reliability of existing assessment tools for fetal growth and fetal heart rate to minimise the risk for babies.
5. HSIB recommends that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record, and also support alerting functionality.
6. HSIB recommends that NHS England and NHS Improvement develop minimum operating standards for interpretation services in maternity care which will include a communication risk assessment.
7. HSIB recommends that NHS England and NHS Improvement leads the development of minimum operating standards for pre assessment maternity telephone triage services to support safe and consistent telephone triage to ensure reliable identification of risks.
8. HSIB recommends that NHS England and NHS Improvement develop a framework to support Trusts to anticipate operational risk in maternity services when delivering neonatal resuscitation.