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Found 554 results
  1. Content Article
    Prisons and Probation Ombudsman (PPO) Sue McAllister has published the independent investigation into the death of a baby (Baby B) at HMP Styal on 18 June 2020. The PPO was concerned that there were missed opportunities to identify the urgent clinical attention that Ms B, the baby’s mother, needed during that evening. The investigation found gaps in prison nurse training about reproductive health, long-acting reversible contraception and recognition of early labour, and the PPO has made recommendations to remedy these issues in all women’s prisons. View the report
  2. News Article
    An inmate gave birth to a stillborn baby in shocking circumstances in a prison toilet without specialist medical assistance or pain relief, an investigation by the Prisons and Probation Ombudsman (PPO) has found. A prison nurse who did not respond to three emergency calls from a prison officer to come to the woman’s aid when she developed agonising stomach cramps has been referred to the Nursing and Midwifery Council. Louise Powell, 31, was unaware that she was pregnant. She gave birth on a prison toilet on 18 June 2020 at HMP & YOI Styal in Cheshire. She previously said she believed her baby girl could have survived had she had more timely and appropriate medical intervention. Her lawyer said they had obtained expert evidence that also suggested that the baby, who Powell named Brooke, may have survived had things been handled differently. The report is the second by the PPO in six months to investigate the death of a baby in prison. While Tuesday’s report found that there had not been failures before the day Powell gave birth, the ombudsman, Sue McAllister, found there were missed opportunities to establish that she needed urgent clinical attention in the hours beforehand. “It’s not safe to have pregnant women in prison, we are just treated like a number,” Powell told the Guardian in a previous interview. “I can’t grieve for my baby yet because there are still things I don’t know, like why an ambulance wasn’t called. I want to get justice for Brooke and I decided to go public in the hope that things will change and pregnant women will stop being imprisoned.” Read full story Source: The Guardian, 11 January 2022
  3. News Article
    Pregnant women are being urged not to delay getting their Covid jab or booster in a government campaign. More than 96% of pregnant women admitted to hospital with Covid symptoms between May and October last year were unvaccinated, according to the UK Obstetric Surveillance System. The campaign will share testimonies of pregnant women who have had the jab on radio and social media. The government said the vaccine was safe and had no impact on fertility. In December, the Joint Committee on Vaccination and Immunisation added pregnant women to the priority list for the vaccine, saying they were at heightened risk from Covid. Around one in five pregnant women admitted to hospital with the virus needed to be delivered pre-term to help them recover, and one in five of their babies needed care in the neonatal unit, the Department of Health and Social Care (DHSC) said. Prof Lucy Chappell, chief scientific adviser to the DHSC, told BBC Radio 4's Today programme that a third of unvaccinated pregnant women with COVID-19 needed help with breathing and one in six were admitted to intensive care. "We've also seen stillbirths and neonatal deaths in the latest wave," she said. Prof Chappell said the vaccine causes pregnant women to produce antibodies against the virus, which cross over to their babies and give them protection too. Dr Jen Jardine, from the Royal College of Obstetricians and Gynaecologists, who is seven months pregnant and has had her booster jab, said: "Both as a doctor and pregnant mother myself, we can now be very confident that the Covid-19 vaccinations provide the best possible protection for you and your unborn child against this virus." Read full story Source: BBC News, 10 January 2022
  4. Content Article
    A midwife in England shares their experiences of working in the NHS in 2021. They describe the mental and physical impact of having to work beyond capacity on a daily basis, a situation caused by a staffing crisis in the midwifery workforce. The impact of this is that more midwives are leaving the NHS as they are unable to cope with these pressures, which makes the workload for remaining staff even heavier.
  5. News Article
    Scottish Liberal Democrat leader Alex Cole-Hamilton is calling for more cash to be invested in drug and alcohol services after “utterly heart-breaking” figures showed at least 852 babies have been born addicted since April 2017. A total of 173 such births were recorded in both 2019-20 and 2020-21, down from 205 in 2018-19 and 249 in 2017-18. In addition to this, a further 52 babies were born addicted in the first part of 2021-22, according to the figures, which were compiled by the Scottish Lib Dems using data obtained under Freedom of Information. Mr Cole-Hamilton described the figures as being “utterly heart-breaking”, adding: “It is hard to think of a worse possible start in life for a newborn baby to have to endure.” He criticised SNP ministers, saying: “In 2016, the Scottish Government slashed funding to drug and alcohol partnerships by more than 20 per cent. Valuable local facilities shut their doors and expertise was lost which has proved hard to replace." “Scotland now has its highest-ever number of drug-related deaths. The Scottish Government has belatedly begun to repair that damage but there is so much more to do." Read full story Source: The Independent, 6 January 2022
  6. Content Article
    This guidance will help Local Maternity Systems align their Equality and Equality Action Plans with Integrated Care Systems health inequalities work. The guidance includes an analysis of the evidence, interventions to improve equity and equality, resources, indicators and metrics.
  7. News Article
    Mothers and babies are being put at risk as vital health checks and support services remain shut months after lockdown was lifted, health professionals and charities have warned. Face-to-face services for new families stopped when lockdown began in March last year and have not come back in many parts of the country. Now experts fear the spread of the Omicron variant and the reintroduction of some restrictions means the reopening will be delayed further. Missing services include drop-in baby-weighing clinics, tongue-tie clinics, face-to-face breastfeeding support and council-run baby classes and playgroups. Experts have accused the government of failing to prioritise the needs of a generation of babies and their parents, with cost-cutting and a shortage of midwives and health visitors blamed for the closures. Health visitor drop-in clinics are “no longer running” in nearly a third of areas, and around 28% of newborn checks are being carried out via phone or video call, according to the No One Wants to See My Baby report by charities the Parent-Infant Foundation, Home-Start UK and Best Beginnings. The Institute of Health Visiting said different interpretations of government guidance meant some areas had brought back full services while others had not, creating a “postcode lottery of support for families”. It questioned official advice that routine checks could continue to be done via video and telephone calls, warning there was no evidence these were “safe or effective”. Executive director Alison Morton said: “Alongside the concerns of parents, there is a growing body of evidence that childhood conditions and disabilities are being missed, and vulnerable babies and young children are being harmed, as they are invisible to services when these assessments are not completed face to face.” Read full story Source: The Guardian, 12 December 2021
  8. Content Article
    This report looks at how the inaccurate use of the skin cleaning agent chlorhexidine in neonatal care caused severe chemical burns to a baby.
  9. Content Article
    This report looks at an incident where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.
  10. News Article
    "You hear his heartbeat and the next thing you know, you've got nothing." A woman whose son was stillborn has said she wants to change the law to enable an inquest to investigate the circumstances surrounding his death. Katie Wood's son Oscar was stillborn on 29 March 2015, but under law in England and Wales, inquests for stillborn babies cannot take place. A consultation was put out by the UK government in March 2019, but the findings have yet to be published. The UK government said it would set out its response in due course, but this delay was criticised by the House of Commons justice committee in September. Katie and her family said they have never received satisfactory answers about why Oscar died. Her pregnancy, while challenging, had not given any serious cause for concern. An investigation by the Aneurin Bevan health board found a number of failings in Katie's care. A post-mortem examination suggested a condition known as shoulder dystocia, where the baby's shoulder becomes stuck during birth, may have contributed, but this is rarely fatal. The health board said it conducted a serious incident investigation into Oscar's death and added: "Whilst we seek to find answers during any investigation, in some cases, a full understanding around the cause of death may not always be achieved and we accept the unavoidable distress this may pose for families." Clinical negligence and medical law specialist, Mari Rosser, says allowing coroners to look into the reasons for a baby's death is long overdue. "Currently parents who suffer a still birth can have the circumstances investigated, but the circumstances are investigated by the health board and of course that's less independent," she said. Read full story Source: BBC News, 9 December 2021
  11. Content Article
    This report looks at how when face-to-face midwife visits were replaced by virtual appointments during the Covid-19 pandemic, the health of the some babies deteriorated. Guidance has been amended to state that initial visits should be face-to-face.
  12. News Article
    Women in prison are five times more likely to have a stillbirth and twice as likely to give birth to a premature baby that needs special care, new data collected by the Observer shows. Following two baby deaths in prisons since 2019 there have been increasing concerns about safety for pregnant women and their babies. Figures obtained through freedom of information requests made to 11 NHS trusts serving women’s prisons in England show 28% of the babies born to women serving a custodial sentence between 2015 and 2019 were admitted to a neonatal unit afterwards – double the national figure, according to data from the National Neonatal Research Database. The findings come as the House of Lords prepares to vote this week on proposed changes to bail and sentencing laws that would improve the rights of pregnant women and mothers facing criminal charges. A report published in September examined the circumstances of a baby’s death at Bronzefield prison in Surrey where an 18-year-old was left to give birth alone in her cell. When Anita rang her cell bell at 5.30am when she went into labour the guards said they would send somebody. It was only during the morning rounds at 7.30am that a nurse was called. She was transferred to hospital at 10.30am. Anita said: “Despite being in active labour the guards would not remove my handcuffs and ignored me when I asked them to call the baby’s father and my mum – who were eventually contacted by a doctor.” Read full story Source: The Guardian, 5 December 2021
  13. News Article
    A couple whose child died in the womb after mistakes by maternity staff have received a £2.8m settlement. Sarah Hawkins was in labour for six days before Harriet was stillborn at Nottingham City Hospital in April 2016. Hospital bosses initially found "no obvious fault", but an external inquiry identified 13 failings in care. Solicitors representing Mrs Hawkins and husband Jack said it was believed to be the largest payout for a stillbirth clinical negligence case. Mrs Hawkins was nearly 41 weeks' pregnant when Harriet was delivered, almost nine hours after dying. The couple were first told their child had died of an infection but refused to accept this and launched their own investigation. A Root Cause Analysis Investigation Report published in 2018 concluded the death was "almost certainly preventable". The report said errors included a delay in applying appropriate foetal monitoring, the important omission of information on an antenatal advice sheet and a failure to follow the Risk Management Policy for maternity. It also found failures to record or pass on information correctly, failure to follow correct guidelines and delays in administering the correct treatment. Following the report's publication, the hospital trust apologised and said major changes would be made. Read full story Source: BBC News, 6 December 2021
  14. Content Article
    This case study looks at the issue of using ethyl chloride spray during fetal blood sampling procedures, which leaves a plastic residue on the babies scalp.
  15. Content Article
    This case study looks at how plastic cord clamps used in caesarean sections are not visible on x-ray, which could be a patient safety issue.
  16. News Article
    The family of a baby who died after errors in her care have criticised the failure of the NHS to learn lessons. Elizabeth Dixon died due to a blocked breathing tube shortly before her first birthday and a subsequent independent investigation found a 20-year cover-up. A year on, Elizabeth's mother Anne told the BBC: "My daughter has not been a catalyst for change." The Department of Health said it was working on the report's recommendations and will publish "a full response". Elizabeth Dixon, known as Lizzie, was born prematurely at Frimley Park Hospital, in Surrey, in December 2000. But a series of errors by the hospital and by Great Ormond Street Hospital, which took over her care shortly after birth, left Elizabeth with brain damage and needing to breathe through a tracheostomy. She was further let down by Nestor Primecare, a private nursing agency, which was hired to support her parents when Elizabeth returned home. She died 10 days before her first birthday. An official investigation, published last year, found a "20 year cover-up" by health workers, with some of those involved described as "persistently dishonest". "I would have expected them to take it seriously," Mrs Dixon said in response to the lack of action. She believes that if a similar incident happened today, there would be a danger it would also be covered up. "That's the default option - if its bad enough, they'll cover up," she said. Read full story Source: BBC News, 1 December 2021
  17. Content Article
    At 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.
  18. Content Article
    Mind the Gap 2021 explores what training looked like for the maternity services workforce during the COVID-19 pandemic, and how this relates to the factors that contribute to the avoidable harm and deaths of mothers, birthing people, and their babies. It is an ongoing piece of research by the charity Baby Lifeline. The report directly surveys recommendations from reports investigating avoidable harm and takes into account wider events affecting maternity care. Training is a central recommendation for improving safety in maternity services. Gaps which already existed in training due to chronic underfunding and staff shortages have become worse, and this report will give recommendations to improve training nationally and locally at a critical time for maternity.
  19. News Article
    Becoming a father can be the happiest time in a man's life, but for some it can bring unexpected feelings of anxiety, stress and guilt. Until recently, mental health concerns for new dads were little understood and, often, went unaired. But some men who have experienced postnatal depression hope telling their stories will encourage others to open up. When Stephen's daughter was born five years ago he knew he was meant to feel happy but instead began to think his wife and newborn child might be better off without him. "You don't get a chance to sit back, take it in, relax and enjoy it," he said. "I'd come home on a weekend after a long week, tired out, and my wife was back at work, working weekends." "It just affects you, you don't see each other, you don't have the chance to enjoy it, and all the stress and anxiety builds up. I got to such a low point I considered my family were better off without me." An international study in 2010 suggested that as many as one in 10 men struggle with postnatal depression (PND). More recently, in 2015, a survey by the National Childbirth Trust (NCT) found one in three new fathers had concerns about their mental health. The NCT has called for more recognition around mental health issues affecting new dads. It has set up Parents in Mind: Partners Project, which offers support to everyone who has an active role raising a child under two. "Becoming a parent is an emotional rollercoaster," said Catherine Briars, who runs the project in St Helens. "Fathers sometimes feel uncomfortable opening up about their feelings but we encourage them to do so if they're struggling. It's often the first step to recovering and regaining good mental health." She said they encourage men to talk to someone they trust or their GP. Read full story Source: BBC News, 19 November 2021
  20. News Article
    A trial testing for Group B Strep during pregnancies has been welcomed by a mum who lost her son to the bacterial infection. The trial at Derriford Hospital will see routine testing for the bacteria that can put newborns at risk. Dawn Byly lost her third child Leo to the infection a day after he was born in Truro in 2003. "I would love to think this might help prevent other families going through such a traumatic loss," she said. About one in four pregnant women are carriers of Group B Strep. Most do not have any symptoms, but it can spread to their child during labour and in a small number of cases the infection can be life-threatening. Currently only women identified as being at risk are tested and if positive are offered antibiotics during labour and birth. Tests are available privately and involve a late swab in pregnancy. "Suffering the loss of a child is a tragedy and we are committed to making sure all women get the right support and best possible maternity care," said the Department of Health and Social Care. "The UK National Screening Committee reviewed the evidence to screen for Group B Strep at 35 to 37 weeks of pregnancy in 2017 and concluded there was insufficient evidence to introduce a national screening programme," it added. Dr Alexander Taylor, from Derriford Hospital in Plymouth, said: "It's felt uncomfortable as an obstetrician in the UK knowing America, Canada and many of our European neighbours have been routinely screening for Group B Strep. "This large trial aims to uncover both the clinical effectiveness but also the cost effectiveness of instituting a programme like this." Read full story Source: BBC News, 9 November 2021
  21. News Article
    A California couple gave birth to a stranger's child after being given the wrong embryo by a fertility clinic during in vitro fertilisation (IVF), says a lawsuit. Daphna and Alexander Cardinale say they gave birth in September 2019 to a girl that looked nothing like them. After a DNA test, they found the couple that carried their daughter to term, and together decided to swap the girls. This is not the first alleged mix-up during an IVF procedure. IVF is a procedure during which a woman's eggs are fertilised by man's sperm in a laboratory before the embryos are implanted into a woman's uterus. The Cardinales are suing the Los Angeles-based fertility centre, the California Center for Reproductive Health (CCRH), as well as In VitroTech Labs, an embryology lab. The lawsuit alleges medical malpractice, negligence and fraudulent concealment. Neither company responded to a BBC News request for comment. In an emotional news conference on Monday, Mrs Cardinale said her family's "heartbreak and confusion can't be understated". "Our memories of childbirth will always be tainted by the sick reality that our biological child was given to someone else, and the baby that I fought to bring into this world was not mine to keep." Read full story Source: BBC News, 9 November 2021
  22. News Article
    Socioeconomic inequalities account for an estimated quarter of stillbirths, fifth of preterm births, and a third of births with fetal growth restriction, according to a study published in the Lancet of over one million births in England The nationwide study across England’s NHS was carried out by the National Maternity and Perinatal Audit team, who analysed birth records between April 2015 and March 2017 to quantify socioeconomic and ethnic inequalities in pregnancy outcomes. They found that an estimated two thirds (63.7%) of stillbirths and half (55.0%) of births with fetal growth restriction in black women from the most deprived neighbourhoods could be avoided if this population had the same risks as white women living in the most affluent 20% of neighbourhoods. Read full story (paywalled) Source: BMJ, 2 November 2021
  23. Content Article
    This 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.
  24. Content Article
    Poppy 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.
  25. Content Article
    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.
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