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Showing results for tags 'Maternity'.
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Content Article
First, Do No Harm — But in a Pandemic, How? (25 September 2020)
Patient Safety Learning posted an article in Blogs
As hospitals in the US braced for the onslaught of coronavirus cases this past spring, they radically restructured and reorganised to help ease the burden on staff and minimise transmission within the hospital. Along with ceasing elective surgeries and transforming floors to allow for care of intubated patients, visitors were forbidden from entering hospitals with few exceptions. Now, several months removed from the peak of the pandemic, a limited number of visitors are allowed at a time. While limiting visitors allows some additional element of physical distancing, how much does a ban actually help our patients, and how much does it hurt them — especially mothers-to-be in the vulnerable perinatal period? Is it possible to limit visitor-spread virus while allowing our patients the dignity and the peace of companionship during one of the most stressful periods of their lives? In this blog, Byrne and Goldfarb look at the consequences of limiting visitors during the pandemic and considers the negative effect this may have on the health of the patient. -
Content ArticleThis study from the THIS Institute, published in BMJ Quality and Safety, seeks to characterise features of safe care in maternity units. Hospital-based maternity units in the study displayed features that reinforce each other to optimise safety. The paper describes these features in a plain language framework, the For Us – For Unit Safety framework. Preventable harm in maternity care has devastating consequences for families, and the associated negligence claims create huge costs for the NHS. Reducing harm in maternity care is a major priority to protect families and NHS sustainability. Much work to date has focused on identifying what goes wrong in maternity care. This study takes a fresh, positive perspective and shares learning about what good looks like for safety in maternity units. The result is the For Us framework, which identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units. The framework doesn’t tell staff working in maternity units what to do. Instead it aims to aid reflection and collective learning and to target improvement efforts. It is an evidence-based framework that aims to support staff working in maternity units to reflect on what good looks like in a safe maternity unit, to identify and agree on priorities for improvement, celebrate achievements, or to make a case for increasing investment to achieve safety.
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Content ArticleLockdown has been a seismic shock for every family and community. Sadly, the voices of the hardest hit have been heard the least. This report sets about to change this by exploring pandemic and lockdown reflections from a diverse group of expectant and new parents during the critical first months and years of their babies’ development. Charities Best Beginnings, Home-Start UK and Parent-Infant Foundation were alarmed that the voices of parents with new babies have been absent from key pandemic responses. As a result, they worked with Critical Research to survey 5,000 new and expectant parents on their lockdown experiences and found a mixed picture, shining a light on huge disparities between different families and communities.
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Content ArticleThis blog, published on the Maternity Experience website, is written by Gill Phillips Director of Nutshell Communications Ltd and creator of the Whose Shoes?® concept and principles. Through her facilitation work, Gill helps people get to the heart of what is important in communication and co-production. Instead of wrapping things up in jargon and complicated language, messages are honest, direct and simple, sourced from what real people are saying. In this blog, Gill talks about the networks that have come together over the past year to explore baby loss and how this work is enabling diverse conversations, rich discussions and a shared commitment to continue improving services for families who experience bereavement.
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Content Article
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'Continuity of carer' in midwifery is when a woman has consistency in who they see during their pregnancy, labour and postnatal period. In this video, three midwives share their experiences of working in this way and talk about the benefits they've seen for women, babies and their own practice. They provide examples of how this model can improve the safety of services and offer advice for teams and individuals embarking on the continuity of carer journey. -
Content ArticleNHS Providers letter to the Health and Social Care Committee calls for sufficient extra recurrent funding to implement the Ockenden recommendations properly and fully.
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Content ArticleMothers and families whose baby was born at an NHS hospital after 1st April 2017 and who may be concerned that their baby sustained a brain injury at birth may be going through an investigation process. This guide, from Action Against Medical Accidents (AvMA), provides mothers and families with information about the process.
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Content ArticleThe Royal College of Obstetrics and Gynaecology (RCOG) has guidance on group B Strep infection in newborn babies, which was last updated in September 2017. A national learning published earlier in 2020 by the Healthcare Safety Investigation Branch (HSIB) highlighted that the RCOG guidance was not being followed. This report from the Group B Strep Support reinforces these findings. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Group B Strep Support recommends that the NHS prioritises the prevention of group B Strep infection in newborn babies. A key step towards this would be to ensure published national guidance from recognised expert bodies is adopted and implemented in a timely manner.
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Content ArticleThis BMJ editorial is written by Marian Knight, professor of maternal and child population health and Charlotte Bevan, a bereaved parent. They argue that systems and thinking need to change, and that our healthcare structures are biased against complexity and are not set up to deliver seamless multidisciplinary care.
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Content ArticleNewborn babies may need extra care in a neonatal intensive care unit or special care baby unit if they were born prematurely or if they need care for a particular health condition. Babies and infants that need long-term care can be transferred to a local unit or discharged to receive care at home. A baby with complex health needs may move between distinct areas of care or 'pathways'. This Care Quality Commission (CQC) review looked at how risks for newborn babies are identified and managed and at the care for infants in the community who need respiratory support. This review draws on one particular case that had a tragic outcome for a baby and her parents. Elizabeth Dixon was born prematurely but suffered brain damage as a result of missed high blood pressure. She died shortly before her first birthday in 2001, when there was a failure to correctly maintain her tracheostomy tube. While this review was not an investigation of the specific circumstances of Elizabeth's case, it drew on this to examine current practice, systems and guidance.
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Content ArticleUK legislation and government policy favour women’s rights to bodily autonomy and active involvement in childbirth decision-making including the right to decline recommendations of care/treatment. However, evidence suggests that both women and maternity professionals can face challenges enacting decisions outside of sociocultural norms. This study, published in PLOS ONE, explored how NHS midwives facilitated women’s alternative physiological birthing choices, defined in this study as ‘birth choices that go outside of local/national maternity guidelines or when women decline recommended treatment of care, in the pursuit of a physiological birth.' Due to the wide range of women’s choices this study reported, the knowledge generated has applications as heuristic knowledge which can be used by midwives more broadly within their clinical care delivery. The benefits being that the findings can be applied to most ‘out of guidelines’ clinical situations by any maternity professional. Delivering such care can be achieved by meaningful engagement with women’; through mechanisms of trust and information sharing, care plans and safety measures can be implemented to support women’s autonomous decision-making.
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Content ArticleThis report, the seventh MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2016 and 2018 in the UK. In addition, it also includes Confidential Enquiries into the care of women who died between 2016 and 2018 in the UK and Ireland from epilepsy and stroke, general medical and surgical disorders, anaesthetic causes, haemorrhage, amniotic fluid embolism and sepsis. The report also includes a Morbidity Confidential Enquiry into the care of women with pulmonary embolism.
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Content ArticleFollowing the publication of Donna Ockenden’s first report: Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust on 11 December 2020, the NHS has issued this latest update. Read previous letter update
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Content ArticleRecent work has emphasised the benefits of patient-physician concordance on clinical care outcomes for underrepresented minorities, arguing it can boost communication and increase trust. Authors of this study explored concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn-physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. They found no significant improvement in maternal mortality when birthing mothers share race with their physician. You can also read the news coverage in the Washington Post here. To access the research, follow the link below.
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Content ArticleThe Early Notifcation scheme is a national programme for the early reporting of infants born with a potential severe brain injury following term labour to NHS Resolution. This leaflet has been produced as an overview to highlight the: key findings of the report six recommendations information on our collaborative partners and other resources available on our website including information on supporting staff and families.
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Content Article
NHS Resolution: Neonatal jaundice (19 October 2018)
Patient Safety Learning posted an article in Maternity
Neonatal jaundice is a common condition which is usually harmless, requires no treatment or responds to phototherapy. On rare but tragic occasions it can cause long-term brain damage with physical and psychological consequences for the family, or death. NHS Resolution reviewed twenty claims for injury secondary to neonatal jaundice which were notified to NHS Resolution between 2001 and 2011 and identified key themes and most common risk factors. -
Content Article
NHS Resolution: Fetal surveillance (16 September 2019)
Patient Safety Learning posted an article in Maternity
This case story is based on real events and NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. -
Content ArticleJames Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance, discusses the findings of the recent Bill Kirkup report 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'.
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Content Article
House of Commons Debate - Ockenden Review
Mark Hughes posted an article in Other reports and inquiries
This debate begins with a statement by the Minister for Mental Health, Suicide Prevention and Patient Safety, Nadine Dorries MP, responding to the publication of the first report by the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust. It is followed by questions from MPs in the chamber and the Minister's responses. -
Content ArticleSerious complications and deaths resulting from maternity care have an everlasting impact on families and loved ones. The families who have contributed to the Ockenden Review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past. The learning of lessons and embedding of meaningful change at The Shrewsbury and Telford Hospital NHS Trust and in maternity care overall is essential both for families involved in this review and those who will access maternity services in the future. After reviewing 250 cases and listening to many more families, this first report identifies themes and recommendations for immediate action and change, both at The Shrewsbury and Telford Hospital NHS Trust and across every maternity service in England.
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Content ArticleWomen from ethnic minorities are voicing their concerns that they face endemic structural racism when seeking and accessing healthcare, and they feel that their symptoms and signs are more often dismissed. It is vital that patients are listened to when they say that they feel this is also due to structural racism in healthcare.
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Content ArticleLaura Anne Jones MS (Member of the Senedd) tabled a formal written question concerning the implementation of the findings of the Cumberlege Review in Wales. This is the formal response from the Minister for Health and Social Services, Vaughan Gething MS.
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Content Article
Breastfeeding and medication
PatientSafetyLearning Team posted an article in Women's health
This website has been developed by Wendy Jones BSc, MSc, PhD, MRPharmS, a Community Pharmacist for over 40 years. This website is designed to provide information and support for mothers and healthcare professionals struggling to balance the benefits of breastfeeding with the perceived risk of exposing the baby to medication through his/her mother’s breastmilk.The information provided is based upon Wendy's many years experience gained as a pharmacist and from running the BfN national Drugs in Breastmilk Help-line. -
Content ArticleA framework has been developed by the Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives and the Society and College of Radiographers, in partnership with NHS England and NHS Improvement, to support maternity services with the local reintroduction of hospital visitors and individuals accompanying women to appointments. This framework has been designed to assist NHS trusts to reintroduce access for partners, visitors and other supporters of pregnant women in English maternity services. It applies to inpatient and outpatient settings. Reintroducing visits is challenging during a pandemic, and the priority must be the safety of all service users (including pregnant women), staff and visitors.
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Content ArticleThis was a debate from the Scottish Parliament on the 8 September 2020 concerning the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). The debate centred on a motion put forward by Jeane Freeman MSP, Cabinet Secretary for Health and Sport, which read as follows: That the Parliament welcomes the recommendations made by Baroness Cumberlege in her report on the independent medicines and medical devices safety review; acknowledges the Scottish Government's apology to women and families affected by Primodos, sodium valproate and transvaginal mesh; welcomes the Scottish Government’s commitment to establish a Patient Safety Commissioner, and notes the actions taken by the Scottish Government to offer improved services for women who have suffered complications as a result of transvaginal mesh.
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