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Found 549 results
  1. Content Article
    This is the first in a series of thematic reports which will be published by the Independent Maternity Services Oversight Panel in the coming year. The purpose of the report is to summarise the learning which is emerging from the ongoing programme of independent clinical reviews of the maternity and neonatal care previously provided by the former Cwm Taf University Health Board. This particular report summarises the key themes and issues which emerged from the clinical review of 28 individual episodes of care1 which were provided by the Health Board between 01 January 2016 and 30 September 20182. It focuses on the care of mothers who needed unplanned emergency treatment during childbirth, including some who required admission to an Intensive Care Unit.
  2. Content Article
    This is the second in a series of thematic reports to be published by the Independent Maternity Services Oversight Panel about their ongoing programme of independent clinical reviews of the maternity and neonatal care provided by the former Cwm Taf University Health Board. This report focuses on the care of mothers and their babies who were stillborn. It summarises the key themes and issues which emerged from the clinical review of 63 individual episodes of care which were provided by the Health Board between 01 January 2016 and 30 September 2018.
  3. Content Article
    On Friday 17 September 2021 the World Health Organization (WHO) held their World Patient Safety Day 2021 Virtual Global Conference, focused on the theme of ‘Safe maternal and newborn care’. This page contains links to a number of presentations from the event.
  4. Content Article
    This is the transcript of a debate in the House of Commons ahead of Baby Loss Awareness Week (9 to 15 October 2021). In this debate, MPs reflected on personal experiences and those of their constituents, the role of Baby Loss Awareness Week as an essential focal point for bereaved families and the potential for the Government to mandate and fund the National Bereavement Care Pathway programme.
  5. Content Article
    This is the Government’s formal response to the recommendations made by the Health and Social Care Committee in its report, ‘The Safety of Maternity Services in England’.  The Committee’s inquiry examined evidence relating to the safety of maternity services. It builds upon current investigations following incidents at East Kent Hospitals University Trust and Shrewsbury and Telford Hospitals NHS Trust, as well as the inquiry into the University Hospitals of Morecambe Bay NHS Trust. The inquiry also considered whether the clinical negligence and litigation processes need to be changed to improve the safety of maternity services and explored the impact of blame culture on learning from incidents. 
  6. Content Article
    Prisons and Probation Ombudsman Sue McAllister has published the independent investigation into the death of a baby (Baby A) at HMP Bronzefield on 27 September 2019. The investigation identified a considerable number of issues and concerns about the care and management of Ms A, the baby’s mother. Sue makes a significant number of recommendations to improve maternity services in Bronzefield. There is wider learning for the whole of the women’s prison estate from the death of Baby A, and the Prison Service must take this opportunity to improve the outcomes for pregnant prisoners so that this tragic event is not repeated.
  7. Content Article
    In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships.
  8. Content Article
    This leaflet has been developed by Tommy’s and NHS England to help pregnant people understand more about their baby's movements, why it is important and when to seek advice. The leaflet contains clear messaging on reduced fetal movements consistent with national guidelines.
  9. Content Article
    Solace is a London-based charity working to end violence against women and girls. In this blog, Chief Executive, Fiona Dwyer highlights the increased risk of abuse during pregnancy and how healthcare staff can help identify and reduce significant harm.  
  10. Content Article
    This is the Herts and West Essex Local Maternity and Neonatal system multilingual maternity resource padlet. It includes resources in multiple languages including Sign Language an in audio form. The initial concept and content was developed by Charlotte Easton, Better Births Project Midwife at West Hertfordshire Hospitals NHS Trust.
  11. Content Article
    Neonatal herpes is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the same virus that causes cold sores and genital infections – the herpes simplex virus (HSV). Early recognition and treatment has been shown to significantly improve babies' chances of making a full recovery. In the first of a series of blogs, Sarah de Malplaquet, Chief Executive and Founder of the Kit Tarka Foundation, explains why they are joint-funding new research into neonatal herpes, and how the findings could help save many lives. 
  12. Content Article
    S. Dorothy Smith instinctively knew that something was wrong with her daughter Katiana, but was dismissed as a hysterical first-time mum who just couldn't cope with normal newborn crying. She wrote a guest post for the Hysterical Women website, which can be accessed via the link below.
  13. Content Article
    This group is designed to bring together mothers (and fathers) of children (of all ages) with a tracheostomy, for support and advice. It is a group for parents only.
  14. Content Article
    Miscarriage for Men, was set up by Chris Whitfield. Chris and his wife Jade suffered a miscarriage in February 2021, and on the back of this, Chris realised that there was very little support or anywhere to turn to for men, who were going through the agony of miscarriage. Men often choose to hide their emotions rather than speak up. This platform is for them to release that emotion, read stories from men in a similar scenario and let them know they are not alone. This website will point people in the direction of guidance, self help techniques to combat these emotions, a forum with real life stories, a chat function and many other helpful tools.
  15. Content Article
    Better Births set out a compelling view of what maternity services should look like in the future. The vision is clear: we should work together across organisational boundaries in larger place-based systems to provide a service that is kind, professional and safe, offering women informed choice and a better experience by personalising their care. Whilst Better Births described the vision, this resource pack sets out in detail what needs to be done and how it can be accomplished across the whole of England. It is designed to provide tools to help Local Maternity Systems turn the vision into reality and the practical advice needed to plan, commission and operate maternity services in their localities.  
  16. Content Article
    For World Patient Safety Day, Natasha Swinscoe, Patient safety national lead for the AHSN Network and CEO, West of England AHSN, highlights the difference the AHSNs and Patient Safety Collaboratives have made in safe maternal and newborn care.
  17. Content Article
    In this blog Patient Safety Learning marks World Patient Safety Day 2021. It sets out the scale of avoidable harm in healthcare, what needs to change to create a patient safe future and considers the theme of this year’s World Patient Safety Day, ‘Safe maternal and newborn care’.
  18. Content Article
    The aim of this qualitative study, published in Midwifery, was to examine how (UK and Australian based) midwifery students, who self-identify as having been bullied, perceive the repercussions on women and their families.
  19. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That’s why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This month, to mark World Patient Safety Day 2021 on the 17 September, we’ve selected seven resources related to this year’s theme, ‘Safe maternal and newborn care’. Shared with us by hub members, charities and patient safety advocates, they provide valuable insights and practical guidance on a broad range of maternity safety topics. 
  20. Content Article
    "My voice didn't matter. I felt like I was being gas lit, and that I wasn't important." Black women report being dismissed and neglected by healthcare professionals throughout pregnancy, childbirth and beyond - and are four times more likely to die in childbirth than women of other ethnicities. Prominent medical committee, NICE, has proposed that inducing pregnant Black women, bringing their birth forward early, could go some way to addressing the problem. The host of this podcast from The Fourcast speaks to a doctor who says it’ll make birth safer for mums and babies, and campaigner Sandra Igwe who says that early induction is not the solution to a deep and complex issue, rooted in racism and inadequate healthcare for Black mothers-to-be.  *Content warning: This episode includes discussion about maternal death and stillbirth.
  21. Content Article
    The Royal College of Obstetricians and Gynaecologists reviewed maternity care at two hospitals:  The Royal Glamorgan hospital Prince Charles hospital The report makes recommendation on improvements to ensure the safety of mothers and babies. "During interviews and in group sessions the assessors were repeatedly and consistently told by staff of a reluctance to report patient safety issues because of a fear of blame, suspension or disciplinary action." "The assessors found little evidence among staff at all levels and professional backgrounds, of a coherent approach towards patient safety, or an understanding of their roles and responsibilities towards patient safety beyond the care they provided for a specific woman or group of women. This perception extended to senior members of midwifery and medical staff."
  22. Content Article
    This joint letter calls on Nadine Dorries MP, Minister for Patient Safety, Suicide Prevention and Mental Health, to urgently fund a confidential enquiry into the deaths of Asian and Asian British babies. It is signed by the Chief Executives of Sands, The Royal College of Midwives, NCT and the President of the Royal College of Obstetricians and Gynaecologists.
  23. Content Article
    In this blog Patient Safety Learning looks ahead to World Patient Safety Day 2021 and considers its theme, ‘Safe maternal and newborn care’.
  24. Content Article
    This is the transcript of a backbench debate in the House of Commons focused on the UK Government's National Maternity Ambition to halve the rate of stillbirths, neonatal and maternal deaths and brain injuries that occur during or soon after birth by 2025, and to achieve a 20% reduction in these rates by 2020.
  25. Content Article
    Group B Streptococcus (Group B Strep, Strep B, Beta Strep, or GBS) is a type of bacteria which lives in the intestines, rectum and vagina of around 2-4 in every 10 women in the UK (20-40%). Most women carrying GBS will have no symptoms and although it is not harmful to pregnant women, it can affect babies around the time of birth. Read Poppy's story.
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