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Found 554 results
  1. News Article
    Stillbirth rates remain "exceptionally high" for black and Asian babies in the UK, a report examining baby loss in 2019 has found. The figures come despite improving numbers overall, with some 610 fewer stillbirths in 2019 than in 2013. The MBBRACE-UK report found babies of mothers living in deprived areas are at higher risk of stillbirths and neonatal deaths than those in other places. Charities say there is an urgent need to tackle inequalities around birth. There were some 2,399 stillbirths (a death occurring before or during birth once a pregnancy has reached 24 weeks) and 1,158 neonatal deaths (babies who die in the first 28 days of life) in the UK in 2019. The report, by the Universities of Leicester and Oxford, found: Overall stillbirth rates fell from 4.2 per 1,000 births in 2013 to 3.35 per 1,000 births in 2019 For babies of black and black British ethnicity, stillbirth rates were 7.23 per 1,000 births For babies of Asian and Asian British ethnicity, stillbirth rates were 5.05 per 1,000 births For babies of white ethnicity, stillbirth rates were 3.22 per 1,000 births. Read full story Source: BBC News, 15 October 2021
  2. Content Article
    MBRRACE-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.
  3. Content Article
    The national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
  4. News Article
    Senior managers at an NHS trust are facing calls to resign from local councillors after criticism of the trust’s culture and widespread bullying. The chair of Nottinghamshire County Council's health scrutiny panel has called for the chair of Nottingham University Hospitals Trust Eric Morton to step down along with Keith Girling, the trust’s medical director. Councillor Sue Saddington, chair of the council’s scrutiny committee, said she would be writing to health secretary Sajid Javid over concerns about leadership at the trust. An investigation by The Independent and Channel 4 News earlier this year uncovered dozens of cases of negligent baby deaths and injuries costing millions of pounds in compensation. Families have accused the trust of trying to cover-up mistakes and not learning from errors. More than 30 babies have died at the trust in the past decade with 46 children left with brain damage. Read full story Source: The Independent, 13 October 2021
  5. News Article
    An adoptive mother is calling for the NHS to improve its diagnosis for children exposed to alcohol in the womb, so their families can be helped. Amanda Boorman's two sons have Foetal Alcohol Spectrum Disorder (FASD) but they were not diagnosed correctly. She said: "This is a brain and body condition that is lifelong so really the professionals need to step up." Foetal Alcohol Spectrum Disorder (FASD) covers the various health and mental issues which can affect children. A spokesperson for the Department for Health and Social Care said: "We are committed to reducing future cases of Fetal Alcohol Spectrum Disorder (FASD) and we have asked NICE [National Institute for Healthcare Excellence] to produce a Quality Standard in England for FASD to help the health and care system improve diagnosis and care of those affected. "We have also published England's first Fetal Alcohol Spectrum Disorders Health Needs Assessment to improve the lives of families living with it and increase understanding amongst clinicians and policy makers." Mrs Boorman, from Brent Knoll in Somerset, said: "There's no way an adoptive parent should ever have to go to a chief executive of a hospital and say 'what is your strategy for diagnosing FASD?' What needs to happen is that clinical commissioning groups, the boards of those, chief executives in hospitals, directors of children's services, social care and education need to be much more proactive." "What we've seen is reactive or just not really knowing - it's complete ignorance." Read full story Source: BBC News. 7 October 2021
  6. Content Article
    Fetal Alcohol Spectrum Disorder (FASD) refers to the range of neurodevelopmental problems caused by pre-natal exposure to alcohol. The effects are diverse and impact on the individual throughout their life course. This document from the Department of Health and Social Care (DHSC) is a health needs assessment for people living with FASD, their carers and families, and those at risk of alcohol-exposed pregnancies in England. The needs identified for this population group focus on: a lack of robust prevalence estimates in England the importance of multi-sector working to support individuals through the life course better training and awareness for health professionals better organisation of services to improve accessibility a need to develop innovative approaches to support those living with the condition.
  7. News Article
    A third of stillbirths at two south Wales hospitals could have been prevented with better care or treatment, an investigation has concluded. It emerged two years ago that more than 60 women suffered the heartbreak of a stillbirth at at the Royal Glamorgan, Llantrisant, and Prince Charles Hospital, Merthyr Tydfil, and that many of these were never reported or investigated. An independent panel set up by the Welsh Government to oversee improvements in these maternity units has now concluded that many of these babies could have been saved. It looked at whether the care provided to women and their babies between January 2016 and September 2018 fell below the standards expected. The failures were split into different levels of severity, known in the report as "modifiable factors". Their investigation looked at 63 stillbirths between January 1, 2016, and September 30, 2018, and discovered that 21 (33%) of them had at least one "major modifiable factor", meaning the stillbirth could potentially have been avoided. More than half (59%) of the 63 had at least one "minor modifiable factor" while in three-quarters (76%) of them "wider learning" was required. In only four of the 63 stillbirths the panel found no modifiable factors. The panel also discovered that "areas for learning" were identified in 59 of the 63 episodes of care reviewed. Read full story Source: Wales Online, 5 October 2021 Read report
  8. 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.
  9. News Article
    Bristol Children’s hospital tried to ‘deceive’ Ben Condon’s parents about his death, NHS ombudsman says An eight-week-old baby died after “a catalogue of failings” in his treatment at a children’s hospital, which then tried to “deceive” his parents about his death, an official inquiry has found. Doctors failed to spot that Ben Condon was suffering from a deadly bacterial infection and did not give him antibiotics until an hour before he died, the NHS ombudsman said. “We found that Ben and his family suffered serious injustice in consequence of the failings we found in his care and treatment,” the parliamentary and health service ombudsman said in a report that contained damning criticisms of Bristol Children’s hospital. The errors were all “lost opportunities” to help Ben recover from his illness and so increased the risk of him dying. Read the full article here Source: The Guardian Also covered in the Independent
  10. 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.
  11. 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.
  12. 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. 
  13. 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.
  14. News Article
    A catalogue of failures among prison and health professionals has been highlighted in an investigation report into the death of a teenager’s baby after she gave birth alone in her cell at the largest women’s prison in Europe. The Prisons and Probation Ombudsman published the devastating report into the events in September 2019 at HMP Bronzefield in Ashford, Middlesex on Wednesday. The case was first revealed by the Guardian and the baby’s death triggered 11 separate inquiries. The report details a disturbing series of events that culminated with the young woman, who cannot be named, being in “constant pain” on the night of 26 September and eventually passing out while giving birth. According to the report the teenager "appeared to have been regarded as difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year-old, frightened that her baby would be taken away”. Failings included: There was confusion among different health professionals about her due date. The day before her baby was born she told a prison nurse she would kill herself or someone else if the baby was taken away from her, but this information was not adequately shared. On 26 September she was put on extended observation, meaning she should have been regularly checked but this did not happen. She rang the bell twice at 8.07pm and 8.32pm that day. A call was connected then immediately disconnected at 8.45pm. She did not press the bell again. Checks by prison officers at 9.27pm and 4.19am revealed “nothing untoward”. It was left to two prisoners to alert staff to the fact that there was blood in her cell at 8.21am on 27 September. Prisons and Probation ombudsman Sue McAllister said: “Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened. Overall, the healthcare offered to Ms A in Bronzefield was not equivalent to that she could have expected in the community.” The publication of the report has triggered multiple calls for an end to the imprisonment of pregnant women from the Royal College of Midwives, NGOs and academics in the field. Read full story Source: The Guardian, 22 September 2021
  15. 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.
  16. News Article
    Babies and mothers are at risk of injury and death because too many maternity units have not improved care despite a string of childbirth scandals, a Care Quality Commission (CQC) report has warned. In a highly critical report published on Tuesday, the CQC voiced serious concern that lessons are not being learned and that many incidents involving patients’ safety are still not being recorded. Some hospitals have been “too slow” to take the steps needed to make labour and birth safer, despite multiple inquiries, reports and recommendations to do so, it said. The CQC also found other persistent weaknesses in maternity care, including tension and difficulties between obstetric doctors and midwives and poor oversight of risks to patients during an in-depth inspection of maternity care at nine hospitals in England. The NHS has been criticised for major maternity scandals involving poor care, which sometimes persisted for many years, at trusts such as Morecambe Bay, East Kent and Shrewsbury and Telford. The government, NHS leaders and patients have pressed the NHS in England to overhaul maternity safety to reduce the number of babies being left brain-damaged or dead and mothers injured or dead as a result of poor care during childbirth. The watchdog also criticised hospitals for doing too little to seek the views from black, minority ethnic and poorer communities about how to improve their experience of giving birth. Black women are four times more likely to die in childbirth than white women, and Asian women twice as likely. “We know that many maternity services are providing good care, but we remain concerned that there has not been enough learning from good and outstanding services,” said Ted Baker, the regulator’s chief inspector of hospitals. Read full story Source: The Guardian, 21 September 2021
  17. News Article
    Folic acid is to be added to UK flour to help prevent spinal birth defects in babies, the government will announce. Women are advised to take the B vitamin - which can guard against spina bifida in unborn babies - before and during pregnancy, but many do not. It is thought that adding folic acid to flour could prevent up to 200 birth defects a year. Mandatory fortification - which the government ran a public consultation on in 2019 - would see everybody who ate foods such as bread getting more folic acid in their diets. Neural tube defects, such as spina bifida (abnormal development of the spine) and anencephaly, a life-limiting condition which affects the brain, affect about 1,000 pregnancies per year in the UK. Many babies diagnosed with spina bifida survive into adulthood, but will experience life-long impairment. Kate Steele, chief executive of Shine, a charity providing specialist support for people affected by spina bifida and hydrocephalus and which has campaigned for mandatory fortification of flour for more than 30 years, said she was "delighted" by the decision. "In its simplest terms, the step will reduce the numbers of families who face the devastating news that their baby has anencephaly and will not survive," she said. "It will also prevent some babies being affected by spina bifida, which can result in complex physical impairments and poor health." Read full story Source: BBC News, 20 September 2021
  18. 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.
  19. 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’.
  20. 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.
  21. 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. 
  22. 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.
  23. 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.
  24. News Article
    Doctors at a hospital in Birmingham mistakenly terminated a healthy unborn baby in a procedure instead of its sickly twin. The unidentified mother decided to abort one of the fetuses because it was suffering from restrictive growth, which increases the chances of stillbirth and puts the healthy baby at risk. During the procedure at Birmingham Women's and Children's NHS Foundation, surgeons accidentally terminated the wrong twin. The 2019 incident emerged in a Freedom of Information Act survey of hospital blunders. Dr Fiona Reynolds, chief medical officer at Birmingham Women's and Children's NHS Trust, said: "A full and comprehensive investigation was carried out swiftly after this tragic case and the findings were shared with the family, along with our sincere apologies and condolences." "The outcome of that thorough review has led to a new protocol being developed to decrease the likelihood of such an incident happening again." Read full story Source: The Independent, 6 September 2021
  25. News Article
    A hospital has admitted liability for the death of a baby who was delivered stillborn three days after his mother’s complaints of fluid loss and severe pain were dismissed as wetting the bed. Jacob Jackson could have been born healthy, Shrewsbury and Telford hospital trust (Sath) has accepted, if it had arranged an earlier delivery in October 2018 as his mother, Charlotte, had suggested. The incident happened 18 months after an external review had been ordered into serious maternity failings at the trust, which are now known to be the biggest maternity scandal in the history of the NHS. Charlotte said: “It makes me feel sick to my stomach that they knew there were problems – this sort of thing had been going on for decades. We keep getting fed the same lines that ‘lessons have been learned’. If lessons had been learned parents and babies wouldn’t be going through this.” Read full story Source: The Guardian, 6 September 2021
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