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News Article
Justice is being denied to too many families
Patient Safety Learning posted a news article in News
Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020 -
News Article
East Kent hospitals: Care watchdog inspects trust after baby death apology
Patient Safety Learning posted a news article in News
England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020- Posted
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News Article
East Kent hospitals: Baby deaths 'could have been prevented'
Patient Safety Learning posted a news article in News
At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found. Significant concerns have been raised about maternity services at the trust. East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care". The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems. In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines. It highlights consultants who: failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested rarely attended CTG training were reported "as doing their own thing rather than follow guidelines". Read full story Source: BBC News, 23 January 2020 -
News Article
NHS maternity scandal: Inquiry into baby deaths now looking at 900 cases
Patient Safety Learning posted a news article in News
The inquiry into Britain's worst maternity scandal is now reviewing 900 cases, a health minister has confirmed. The Ockenden Review, which was set up to examine baby deaths in the Shrewsbury and Telford Hospital Trust, was initially charged with examining 23 cases, but Nadine Dorries, a health minister, confirmed to the Commons that an additional 877 cases are being reviewed. A leaked report in November said a "toxic culture" stretching back 40 years reigned at the hospital trust as babies and mothers suffered avoidable deaths. The review will conclude at the end of the year. Jeremy Hunt, the former health secretary, said it was "deeply shocking" to hear of the new details and asked that the inquiry is "resolved as quickly as possible". Read full story Source: The Telegraph, 16 January 2020- Posted
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- Patient death
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News Article
'Breaking point': fears over lack of intensive care beds for children
Patient Safety Learning posted a news article in News
Critically ill children are being rushed from one part of England to another because NHS hospitals are running short of intensive care beds in which to treat them, the Guardian has revealed. An increase in severe breathing problems in children driven by winter viruses and infections, including flu, means some are having to be transferred sometimes many miles from their home area because there are not enough paediatric intensive care (PICU) beds locally. Specialist doctors who staff the units say the situation is “dangerous and rotten for the families” involved and that staff are firefighting to handle the number of children needing sometimes life-saving care, many of whom are on a ventilator to help them breathe. In the past few weeks, young patients have been sent from the Midlands to Sheffield, from London to Cambridge, and from one side of the Pennines to the other in order to get them a place in a PICU. One doctor at a PICU in the Midlands said: “PICU beds are always in high demand. But since winter hit this year, around six weeks ago, the situation feels like we are simply firefighting. Many days I come on shift to find there are no beds in [our] region and the patients referred to us end up in Southampton, Sheffield, Oxford and other centres far away." “The PICU network is overstretched. There aren’t enough beds, nurses or skilled doctors.” Read full story Source: The Guardian, 29 December 2019- Posted
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News ArticleSick newborns in some areas of the UK are dying at twice the rate of seriously ill babies in other areas, a new report has revealed. The findings raise serious questions about the quality of care in some neonatal units, with experts warning action needs to be taken to tackle the “striking variation”. Across the country neonatal units are also short of at least 600 nurses with four in five failing to meet required safe staffing levels for specialist nurses. The regions with the highest mortality rate at 10 per cent were Staffordshire, Shropshire and the Black Country, where 107 babies died. This compared with a rate of 5 per cent in north central and northeast London. The Shropshire region includes the Shrewsbury and Telford Hospitals Trust, which is at the centre of the largest maternity scandal in the history of the NHS, with hundreds of alleged cases of poor care now under investigation. Dr Sam Oddie, a consultant neonatologist at Bradford Teaching Hospitals Trust and who led the work for the Royal College of Paediatrics and Child Health, said he was “surprised and disappointed” by the differences in death rates between units. “The mortality differences are very striking, with some units having a mortality rate twice that of the lowest. This variation in mortality is a basis for action by neonatal networks to ensure they are doing everything they can to make sure their mortality is as low as possible,” he said. Read full story Read MBBRACE-UK report Source: The Independent, 18 December 2019
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News ArticleMaternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said. A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year. An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018. Read full story Source: The Independent, 6 December 2019
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Content ArticleThis report by the charity Maternity Action looked at the lived experience of pregnant women seeking asylum in the UK. It highlights that pregnant women face barriers in accessing appropriate housing and nutrition during pregnancy, and that midwives and voluntary sector organisations play an important role in supporting pregnant women seeking asylum.
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Content ArticlePreventable harm continues to occur to critically ill premature babies, despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. This article in the Journal for Healthcare Quality describes the introduction of a robust process improvement (RPI) program at a NICU in a US children's hospital. Leaders, staff, and parents were trained in RPI concepts and tools and given regular mentoring for their improvement initiatives, which focused on central line blood stream infections, very low birth weight infant nutrition and unplanned extubations. The authors conclude that implementing the RPI program resulted in significant and sustainable improvements to reduce harm in the NICU.
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Content ArticleThe newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
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Content ArticleThis World Health Organization (WHO) guideline aims to improve the quality of essential, routine postnatal care for women and newborns with the ultimate goal of improving maternal and newborn health and well-being. It recognises a “positive postnatal experience” as a significant end point for all women giving birth and their newborns, laying the platform for improved short- and long-term health and well-being. A positive postnatal experience is defined as one in which women, newborns, partners, parents, caregivers and families receive information, reassurance and support in a consistent manner from motivated health workers; where a resourced and flexible health system recognises the needs of women and babies, and respects their cultural context. This is a consolidated guideline of new and existing recommendations on routine postnatal care for women and newborns receiving facility- or community-based postnatal care in any resource setting.
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- Obstetrics and gynaecology/ Maternity
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Content ArticleThis is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
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Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content ArticleAt the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable. Suzanne White, a former radiographer and a clinical negligence lawyer for the past 25 years, looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
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Content ArticleVery preterm infants are at increased risk of adverse outcomes in early childhood. This study in The Lancet Child & Adolescent Health assessed whether delayed clamping of the umbilical cord reduces mortality or major disability at two years. The authors found that clamping the umbilical cord at least 60 seconds after birth reduced the risk of death or major disability at two years by 17%, reflecting a 30% reduction in relative mortality with no difference in major disability.
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Content ArticleMatthews et al. investigated inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk. They found that stillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.
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Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old.
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Content ArticleThe aim of this study from Liu et al. was to assess the impact of the Fetal Medicine Foundation (FMF) first trimester screening algorithm for pre-eclampsia on health disparities in perinatal death among minority ethnic groups.
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Content Article
HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance.- Posted
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Content ArticleThis nationwide study of over 1 million births in the English NHS between 2015 and 2017, published in The Lancet, has found large inequalities in pregnancy outcomes between ethnic and socioeconomic groups in England. The findings from Jardine et al. suggest that current national programmes to make pregnancy safer, which focus on individual women's risk and behaviour and their antenatal care, will not be enough to improve outcomes for babies born in England. The authors say that to reduce disparities in birth outcomes at a national level, politicians, public health professionals, and healthcare providers must work together to address racism and discrimination and improve women's social circumstances, social support, and health throughout their lives.
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Content ArticlePoppy Harris was born at Milton Keynes University hospital on 23 November 2020. Following a protracted labour, she was delivered using Kielland's forceps. She was transferred to John Radcliffe Hospital in Oxford where it was discovered that she had suffered a spinal cord injury and despite all efforts and care she died on 24 March 2021.
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Content ArticleThis short article describes how maternity and neonatal teams across Herefordshire and Worcestershire Local Maternity and Neonatal System (LMNS) have been using video conferencing technology to drive safety improvements for mothers and babies, thanks to the launch of their new daily digital safety huddles.
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Content ArticleMBRRACE-UK is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to undertake the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). The aims of the MNI-CORP are to collect, analyse and report national surveillance data and conduct national confidential enquiries in order to stimulate and evaluate improvements in health care for mothers and babies. This report focuses on the surveillance of perinatal deaths from 22+0 weeks gestational age (including late fetal losses, stillbirths, and neonatal deaths) of babies born between 1st January and 31st December 2019.
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