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News Article
Archie Batten: Inquest hears baby's mother was turned away from maternity unit
Patient Safety Learning posted a news article in News
The parents of a baby boy who lived for just 27 minutes have told an inquest they were "completely dismissed" throughout labour. Archie Batten died on 1 September 2019 at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, Kent. His inquest began on Monday at Maidstone Coroner's Court. The East Kent Hospitals University NHS Foundation Trust has already admitted liability and apologised for Archie's death. The coroner heard Archie's mother Rachel Higgs was frustrated at being turned away from the maternity unit in the morning, when she had gone to complain of vomiting and extreme pain. She was told she was not far enough into labour to be admitted. She returned home to Broadstairs with her partner Andrew Batten, but continued to feel unwell so phoned the hospital. She was told the unit was now closed. Instead, two community midwives were sent to their home, where they attempted to deliver the baby but could not find a heartbeat. Andrew Batten told the inquest the midwives looked "terrified," and that there was "an air of panic", with the midwives whispering in the hallway instead of telling him and Ms Higgs what was happening. Under examination from the family's barrister Richard Baker, Victoria Jackson, the midwife who had originally seen Ms Higgs, admitted the high number of patients she was having to deal with had affected her ability to spend time with her. Read full story Source: BBC News, 14 March 2022 -
News Article
Midwife struck off over Shropshire baby's death
Patient Safety Learning posted a news article in News
A midwife found guilty of misconduct over the death of a baby six years ago is to be struck off. Claire Roberts was investigated by the Nursing and Midwifery Council (NMC) for failures in the care she gave to Pippa Griffiths - who died a day after being born at home in Myddle, Shropshire. An independent disciplinary panel described the midwife as "a danger to patients and colleagues". Ms Roberts and fellow midwife Joanna Young failed to realise the "urgency" of medical attention needed, following the birth, the panel said. They had failed to carry out a triage assessment, after Pippa's mother called staff for help because she was worried about her daughter's condition. The panel concluded Ms Roberts's fitness to practise was impaired. Inaccurate record-keeping by Ms Roberts represented "serious dishonesty", panel chair David Evans said, adding she had carried it out "in order to protect herself from disciplinary action". Her failures had represented a "significant departure from standards expected by a registered midwife," he added. Her colleague Ms Young, whose case was also heard by the panel, faced strong criticism on Wednesday, but was told she would face no sanction after the hearing concluded she had shown remorse and undergone extra training since 2016. Kayleigh Griffiths said she and her husband welcomed the findings and sanctions. "We're really relieved that one of the midwives has been struck off and actually we're also relieved to find that the other midwife has learnt and feels significant remorse for the event that took place," she said. "We realise people do make mistakes and I think how you deal with those mistakes is really important. "All we do ask is that learning was made from those and I think in one of the instances it did occur and in the other it didn't - so I think the right outcome has been found." Read full story Source: BBC News, 10 March 2022 -
News Article
Shropshire baby deaths: Ockenden report delayed for second time
Patient Safety Learning posted a news article in News
The publication of a report into failures of maternity care at an NHS trust has been delayed again. Senior midwife Donna Ockenden has been investigating hundreds of cases in which mothers and babies may have been harmed at Shrewsbury and Telford Hospital NHS Trust (SaTh). Her report had been due to be published on 22 March after being postponed from December. In a letter to families, Ms Ockenden said that date "can no longer happen". She added it was down to "parliamentary processes" which have to happen before the final report can be published. A written statement to Parliament on Tuesday by patient safety minister Maria Caulfield said the NHS had been working to get indemnity cover. She said it would be to cover any potential legal action following the publication of the report and had been agreed in principle by the Treasury. Ms Ockenden's team has been examining 1,862 cases and it is thought to be the largest ever review of maternity care in the NHS. Her interim report published in December 2020 found some mothers were blamed for their babies' deaths. In her letter about the delay, Ms Ockenden said she and her team were "also very disappointed in the delay" and would be working to agree a new publication date. Read full story Source: BBC News, 9 March 2022 -
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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News Article
Pregnancy risk tool cuts baby loss in black and Asian women
Patient Safety Learning posted a news article in News
A new pregnancy screening tool cuts the risk of baby loss among women from black, Asian and ethnic minority backgrounds to the same level as white women, research suggests. The app calculates a woman's individual risk of pregnancy problems. In a study of 20,000 pregnant women, baby death rates in ethnic groups were three times lower than normal when the tool was used. Experts say the new approach can help reduce health inequalities. The screening tool is already in use at St George's Hospital in London and is being tried out at three other maternity units in England, with hopes it could be rolled out to 20 centres within two years. Researchers from Tommy's National Centre for Maternity Improvement, led by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, developed the new tool. Professor Basky Thilaganathan, who led the research team at St George's Hospital, said the new approach could "almost eliminate a large source of the healthcare inequality facing black, Asian and minority ethnic pregnant women". "We can personalise care for you and reduce the chances of having a small baby, pre-eclampsia and losing your baby," he said. The current system of a tick-box checklist to assess pregnancy risk has been around for 70 years, and is limited. The new digital tool, which uses an algorithm to calculate a woman's personal risk, can detect high-risk women more accurately and prevent complications in pregnancy, the researchers say. Both pregnant women and maternity staff can upload information on their pregnancy and how they are feeling to the app during antenatal appointments and at other times. Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said it was "unacceptable" that black, Asian and minority ethnic women faced huge inequalities on maternity outcomes. "The digital tool provides a practical way to support women with personalised care during pregnancy and make informed decisions about birth. Read full story Read Tommy's press release Source: BBC News, 28 February 2022 -
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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News Article
Mothers who helped uncover the biggest NHS maternity scandal
Patient Safety Learning posted a news article in News
Next month, a report will be published into one of the biggest scandals in the history of the NHS, the failures of maternity care at the Shrewsbury and Telford Hospital NHS Trust. The BBC's Michael Buchanan who helped uncover the problems examines why so many failures were allowed to happen for so long. Kayleigh Griffiths' baby, Pippa, died at 31 hours old. The cause of death, the couple were later told, was an infection - Group B Strep. The Shrewsbury and Telford Hospital NHS Trust told the family they would carry out an investigation. But after several weeks of silence, Kayleigh contacted the trust to be told it was an internal investigation and the couple's input wouldn't be required. Kayleigh, an NHS auditor at a different trust, feared the truth was being hidden from her. That's when she decided to send the email to Rhiannon Davies, whose baby, Kate, also died at the Shrewsbury and Telford Hospital NHS Trust As the bond between the mothers deepened, their conversations morphed into something else. Armed with little more than a gnawing suspicion, they started to scour the internet, coroner's records and death notices to see if any other families had received poor maternity care at the Shropshire trust. They collated 23 cases dating back to 2000 - including stillbirths, neonatal deaths, maternal deaths and babies born with brain injuries. Appalled by what they had found, they wrote to the then health secretary Jeremy Hunt in December 2016, asking him to order an investigation. He agreed and in May 2017, senior midwife Donna Ockenden was appointed to lead the review. One of the themes the inquiry has already noted, in an interim report published in December 2020, is that in many cases the trust failed to investigate after something went wrong, or simply carried out its own inquiry. Panorama has discovered the trust even developed its own investigation system, what they called a High Risk Case Review. It was outside any national framework that has been used to help learn lessons from incidents and doesn't appear to be a system that's used in any other NHS organisation. Another consequence of the unorthodox system was that fewer incidents were reported to NHS regulators, limiting the opportunity to learn lessons. One of the earliest cases on the original list of 23 compiled by the two couples was the death of Kathryn Leigh in 2000. Panorama has investigated the case and discovered that a theme identified almost two decades ago was to come up repeatedly in subsequent incidents. The publication of the final report by Donna Ockenden next month will be a watershed moment in the history of the NHS - the revelation of multiple instances of maternity failures in a rural corner of England. Pippa Griffiths and Kate Stanton-Davies lived fewer than 40 hours between them, but their legacy, in terms of improved maternity care, could last decades. Read full story Source: BBC News, 23 February 2022 Source: -
News Article
Baby deaths force end to NHS targets for natural births
Patient Safety Learning posted a news article in News
The NHS has abandoned targets that encouraged hospitals to pursue “normal births”, over fears for the safety of mothers and babies. Maternity units were told in a letter to stop using caesarean section rates to assess their performance. It comes after repeated scandals in maternity units, blamed in part on a focus on pursuing natural births at the expense of safety. The letter from Jacqueline Dunkley-Bent, NHS England’s chief midwife, and Dr Matthew Jolly, the national clinical director for maternity, instructed “all maternity services to stop using total caesarean section rates as a means of performance management”. It added: “We are concerned by the potential for services to pursue targets that may be clinically inappropriate and unsafe in individual cases." A final report into the deaths of dozens of babies at the Shrewsbury and Telford Hospital NHS Trust will be published next month. It is expected to be highly critical. The midwife leading the inquiry, Donna Ockenden, has said women “felt pressured to have a normal birth” at the trust, adding: “There was a multi-professional, not midwife-led, focus on normal birth pretty much at any cost.” Hayley Coates, 29, lost her son Kaylan after staff at Nottingham University Hospitals NHS Trust ignored her pleas for a caesarean section in March 2018. A coroner ruled that neglect contributed to Kaylan’s death. He suffered a fractured skull when he was delivered with forceps and was starved of oxygen. Coates, a mother of three, said she welcomed the NHS England letter, adding: “I was just ignored when I asked multiple times for a caesarean section. I was told repeatedly: ‘You will have this baby naturally, you don’t want to go to theatre.’ If I had gone to theatre many hours before, my baby wouldn’t have died. They have a duty of care, and the mother’s wishes are supposed to be priority.” Read full story (paywalled) Source: The Times, 20 February 2022 -
Content Article
This joint letter calls on Maria Caulfield MP, Parliamentary Under Secretary of State for Patient Safety and Primary Care, to implement in full the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review on behalf of those harmed by the side effects of Primodos, Mesh and Sodium Valproate. It is signed by Marie Lyon from the Association for Children Damaged by Hormone Pregnancy Tests, Kath Sansom from Sling The Mesh and Emma Murphy and Janet Williams from In-Fact. -
Content ArticleThe 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.
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Content Article
RCM - Midwife number slumps (7 February 2022)
Patient-Safety-Learning posted an article in Maternity
In this blog, Stuart Bonar, Public Affairs Advisor at the Royal College of Midwives, looks at the growing midwifery workforce crisis in the UK. For the first time since records began, the number of midwives is falling year-on-year. The impact on those midwives who remain in the NHS is bigger workloads and decreasing wellbeing. The author calls on the government to pay attention to the situation, and suggests that an adequate pay rise for midwives and midwifery assistants should be part of the solution to falling staff numbers. -
Content ArticleThis study in Patient Education and Counseling aimed to systematically review parental perceptions of shared decision-making (SDM) in neonatology, and identify barriers and facilitators to implementing SDM. The study identified the following key barriers to SDM: Emotional crises experienced in the NICU setting Lack of medical information provided to parents to inform decision-making Inadequate communication of information Poor relationships with caregivers Lack of continuity in care Perceived power imbalances between HCPs and parents. It also identified the following key facilitators for SDM: Clear, honest and compassionate communication of medical information Caring and empathetic caregivers Continuity in care Tailored approaches that reflected parent’s desired level of involvement.
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News ArticleThe US Food and Drug Administration (FDA) is warning healthcare providers, parents and caregivers of pediatric patients (children) who receive enteral feeding that there is a risk of strangulation from the use of enteral feeding delivery sets. The feeding set tubing can become wrapped around a child’s neck and cause strangulation or death. The FDA has received reports of two toddlers who died after being strangled by the tubing. Recommendations for parents and caregivers of children who use enteral feeding delivery sets: Be aware that the feeding set tubing can get wrapped around a child’s neck, which can lead to strangulation or death. To the extent possible, avoid leaving the feeding set tubing where infants or children can become entangled. Discuss with your child's health care provider: If your child has been tangled in their tubing before. Steps you can take to help ensure that tubing does not get wrapped around your child’s neck, such as keeping the tubing away from the child as much as possible. Any other concerns you may have about the risk of strangulation from feeding set tubing. If your child is injured by feeding set tubing, please report the event to the FDA. Your report, along with information from other sources, can provide information that helps improve patient safety. Recommendations for healthcare providers: Review this topic and the information noted above with your colleagues, care teams, and caregivers of pediatric patients who use enteral feeding delivery sets, to ensure they are aware of the potential risk of strangulation with the associated tubing and are taking appropriate measures to keep the tubing away from the child as much as possible. When caring for pediatric patients who receive enteral feeding and as part of an individual risk assessment, be aware of the risk of strangulation from the feeding set tubing and follow protocols to monitor medical line safety. If a patient experiences an adverse event related to enteral feeding set tubing, you are encouraged to report the event to the FDA. Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with medical devices. Read full story Source: FDA, 8 February 2022
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Content ArticleThe British Association of Perinatal Medicine is inviting parents of babies who have spent time in a neonatal intensive care unit (NICU) to submit questions for neonatal research to the Neonatal Priority Setting Partnership. The partnership is made up of healthcare professionals and parent representatives that have come together to oversee a process to identify and prioritise research questions that can be tested in randomised trials in UK neonatal care. Answers to the questions submitted should improve neonatal care and reduce unwanted variations in practice. Questions can be submitted until 28 February 2022.
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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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News Article
New mothers left alone and in pain as maternity crisis worsens
Patient Safety Learning posted a news article in News
Unable to move and with her newborn baby crying out of reach, Neya Joshi was left alone for hours on an understaffed maternity ward and had to beg for a glass of water. “It was awful, I was so helpless and so desperate, and no one was interested in helping me. I have never felt fear like it,” she said. The medical copywriter, 30, was diagnosed with post-traumatic stress disorder months after giving birth to her son Arjun at Croydon University Hospital in May 2020 and had therapy for a year to recover from the trauma. She is one of thousands of mothers across the country experiencing poorer care because maternity units lack enough staff. Data from 122 NHS trusts in England shows maternity units were forced to shut their doors to women in labour more than 323 times in 2020-21, with units shut for a total of 16,294 hours, the equivalent of 679 days. When this happens women are forced to go to an alternative hospital to give birth. Staffing shortages were given as a reason in more than two-fifths of the closures. Joshi saw first hand the impact of a lack of midwives when she was admitted to hospital to be induced after her waters broke at the height of the pandemic. Visiting restrictions meant she was alone on a ward for 24 hours and, despite being told she was a high priority, there were no free beds. “After they had started the induction I was told someone would come and check me within six hours but no one came and I was just left on my own for hours,” she said. Eventually, after concerns over her baby’s heart rate, she had an emergency caesarean section but her husband was then made to leave an hour later. “I was taken to the postnatal ward and that’s where it all really went downhill,” she said. “It was awful. I was just lying there. I couldn’t move because I had the epidural and my baby was crying." Read full story (paywalled) Source: The Times, 6 February 2022 -
Content ArticleThis index of medications provides evidence-based patient leaflets about the use of different medicines in pregnancy. The leaflets are produced by the UK Teratology Information Service (UKTIS). Women can look up medications to understand their impact on pregnancy and how they may affect the chances of miscarriage and birth defects, and provide information on their own pregnancy to add to the knowledge base around medicines in pregnancy.
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Content ArticleThis campaign from Kit Tarka Foundation aims to remind anyone coming into contact with a young baby to remember their T-H-A-N-K-S: Think Hands And No Kisses. Young babies are particularly susceptible to infections, but many people are unaware of the risks and what they can do to reduce them.
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Content ArticleMollie Daisy Dimmock died from perinatal asphyxia due to hypoxia 34 minutes after being delivered. This was caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Mollie was fully delivered. In his report, the Coroner Crispin Butler raises concerns about the NICE guidance in relation to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
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News Article
Babies at risk’ as NHS faces losing nearly one in 10 midwives over mandatory jabs
Patient Safety Learning posted a news article in News
The NHS could be forced to dismiss almost 2,000 midwives by the government’s mandatory vaccination policy, amid warnings from a former chief nurse of England that mothers and babies will be put at risk. Well-placed senior sources have told HSJ around 1,700 midwives remain unvaccinated nationally, according to the latest data from trusts. Based on official headcount data that would amount to between 6.5-8% of the workforce, depending on whether it counts full time equivalent or total staff numbers. However, they are mostly in London, with the latest estimate in the city said to be about 680 (representing between 12 and 14% of the workforce), several well placed sources told HSJ, meaning its maternity services could be seriously destabilised. A former chief nurse of England, Sarah Mullally, who now sits in the House of Lords as the Bishop of London, said she believed about 12.5% of London’s midwives were unvaccinated, and called on the government to delay the mandatory health worker vaccination policy. Speaking in Parliament yesterday, she warned mothers and babies would be put at risk, “in order to implement a policy that has been superseded by the evolution of the virus”. She added: “I would strongly encourage everyone, including NHS staff and health care workers, to get fully vaccinated. However, having heard from midwives myself this week, I can see the anxiety that the requirement for mandatory vaccination is causing, as well as the potential risks to the heath service and its patients. Read full story (paywalled) Source: HSJ, 21 January 2022 -
Content ArticleIn this podcast, Gill Phillips speaks to Nadia Leake and Rachel Collum, parents of premature babies who had long stays in neonatal care after birth, about the importance of Family Integrated Care. Gill developed Whose Shoes?® as a tool to allow people to 'walk in other people's shoes'. Through a wide range of scenarios and topics, Whose Shoes?® helps groups explore many of the concerns, challenges and opportunities facing the different groups affected by the transformation of health and social care.
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News Article
Mum tells of heartbreak at baby loss in Covid coma
Patient Safety Learning posted a news article in News
A woman has spoken of her "devastation" after losing a baby delivered while she was in an induced coma with Covid. Rachel, from Wolverhampton was admitted to hospital over the summer in the 19th week of pregnancy. She said uncertainty about whether pregnant women should have the Covid vaccine had put her off getting it. Her condition deteriorated and she said she was so ill she did not realise at first son Jaxon was stillborn. "I was heavily sedated a lot of the time and from what I'm told by my family, my chances weren't looking very good," the 38-year-old said. "They were trying to get the baby to survive to 28 weeks but unfortunately, at 24 weeks, my son was born stillborn." Rachel, who said she had planned to have the vaccine after giving birth, is now urging others to get the jab, particularly women from minority backgrounds, for whom uptake is lower. Read full story Source: BBC News, 15 January 2022 -
News ArticleMore than £100 million has been paid out in damages by one hospital trust over 10 years after its maternity units were accused of being responsible for dozens of deaths and stillbirths, Channel 4 News has revealed. From April 2010 to March 2021, £103,097,198 was paid out by the Mid & South Essex NHS Foundation Trust involving 176 obstetrics claims, according to NHS Resolution figures obtained by a freedom of information request. Of those claims made against the trust, 36 related to mothers and children dying, 27 referred to stillbirths and 55 concerned babies born with brain damage or cerebral palsy. Gabriela Pintilie died in Basildon University Hospital, which is run by the trust, in 2019 after losing six litres of blood giving birth, and a coroner said there were “serious failings” in her care. Basildon University Hospital’s maternity unit was twice rated inadequate in 2020, following two separate inspections, with a report saying the service “did not always have enough staff to keep women safe”. The report also criticised “longstanding poor staff culture” which had “created an ineffective team”. In August 2020, the Care Quality Commission (CQC) issued a warning notice to the hospital as inspectors found six serious incidents occurred between March and April that year in which babies were born in a poor condition starved of oxygen and at risk of brain damage. Read full story Source: Channel 4 News, 14 January 2022
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Content Article
The State of the World's Midwifery 2021
Patient Safety Learning posted an article in Maternity
The State of the World’s Midwifery (SoWMy) 2021 builds on previous reports in the SoWMy series and represents an unprecedented effort to document the whole world’s Sexual, Reproductive, Maternal, Newborn and Adolescent Health (SRMNAH) workforce, with a particular focus on midwives. It calls for urgent investment in midwives to enable them to fulfil their potential to contribute towards UHC and the SDG agenda.
