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News Article
NHSE funding policy risks ‘levelling down’ maternity safety, warns hospital chief
Patient-Safety-Learning posted a news article in News
Glen Burley, an acute trust chief executive has said NHS England risks ‘levelling down’ safety in some maternity services by ‘disproportionately’ directing additional funding to struggling trusts. This comes after NHS England said the funding prioritised the trusts which needed the most support to meet the essential actions in the Ockenden Report, where in March, NHSE invited trusts to bid for a share of £96m extra funding for maternity services. A spokeswoman for NHS England has said: “The NHS made an additional £96m investment in maternity services following the Ockenden Review, the majority of which will bolster the workforce by funding an additional 1,200 midwives and 100 obstetricians. While the funding for additional workforce is for all NHS trusts, it is right that those who most need the support are prioritised.” Read full story. Source: HSJ, 02 September 2021 -
News ArticleAccording to a new study, mothers at risk of premature birth could be identified as soon as 10 weeks into their pregnancy. The study, conducted by King's College London and published in the Journal of Clinical Investigation, found that by looking for specific bacteria in the in a pregnant woman’s cervicovaginal fluid, it could reveal warning signs for premature birth, meaning inflammation can be found and treated early to protect mothers and babies. Study author Andrew Shennan OBE, who is Professor of obstetrics at King’s College London, explained: “Premature birth is very hard to predict, so doctors have to err on the side of caution and mothers deemed to be at risk often don’t actually have their babies early, putting undue strain on everyone involved. My team has developed preterm birth prediction tools that are very accurate later in pregnancy, like fetal fibronectin tests – but at that stage, you can only manage the risks, not stop it from happening. The sooner we can find out who’s at risk, the more we can do to keep mothers and babies safe.” Read full story. Source: The Independent, 23 August 2021
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News Article
NHS England maternity services may need overhauling to ensure safety, say experts
Patient-Safety-Learning posted a news article in News
At a virtual event held by The Independent last night, experts agreed maternity services needed to be overhauled. The panel discussion, NHS maternity scandal: Inside a crisis, laid out the facts surrounding the problems around maternity care and concerns around safety amid repeated examples of poor care in multiple cases. Donna Ockenden, a senior midwife who has been leading the inquiry into maternity services at Shrewsbury and Telford Hospitals explained "I think one of the major issues around maternity services is that we’re not treated in the same way as A&E. I think that people fail to see that actually, maternity is a woman’s A&E department, you can start a shift in any maternity unit, you can plan what you think you’re going to do. But actually you don’t know what is going to come in the front door.” Read full story. Source: The Independent, 12 August 2021 -
News Article
CQC found emergency caesarean taking place without basic safety measures
Patient-Safety-Learning posted a news article in News
After an unannounced inspection at the Princess Alexandra Hospital Trust in June, the Care Quality Commission (CQC) found an “emergency c-section was being performed without the correct equipment available to monitor the mother”. According to reports, the inspectors stepped in immediately to raise concerns, which was then corrected straight away. In a letter to the trust, the CQC wrote, “Overall, we were concerned that the safety culture in the service was underdeveloped. There were no dedicated maternity safety huddles in line with national guidance. Handovers doubled up as safety huddles. During our observations of handovers, we saw that staff did not discuss safety issues and the format was not safety focused.” Read full story (paywalled). Source: HSJ, 6 August 2021- Posted
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News Article
Midwives reveal their fears for the safety of mothers and babies
Patient-Safety-Learning posted a news article in News
Midwives working at the Nottingham University Hospitals (NUH) Trust have told The Independent that "women are still at a risk of harm". This comes after Nottingham hospitals were investigated after it was found there was a high number of baby deaths and injuries on the maternity ward. However, midwives have revealed to The Independent that there are still not enough resources and support to help women deliver their babies safely. One midwife working in the community told The Independent: “They keep saying ‘We’ve learned our lessons, it’s not like that now’ – but it’s even worse now. It’s worse because we know about it and it’s still bad. Women are still at risk of harm. Even more so in the community.” Read full story. Source: The Independent, 25 July 2021 -
News Article
Nottingham maternity scandal: families want independent inquiry
Patient-Safety-Learning posted a news article in News
More than 20 families have said they want a completely independent inquiry into maternity services at Nottingham University Hospitals (NUH) NHS Trust. One mother, Hayley Coates has said her baby was delivered with forceps, a fractured skull and was starved of oxygen, suffering major brain injuries after a very difficult labour. An inquest this year found serious failings in the service Hayley received after her baby Kaylan, died of an infection a week later. "I was pushing and pushing and nothing was happening. I kept saying the baby isn't coming and I need to go for a Caesarean, but staff kept saying I was going to have the baby naturally," Hayley has said. NUH chief executive Tracy Taylor has said, "We apologise from the bottom of our hearts to the families who have not received the high level of care they need and deserve, we recognise the effects have been devastating". Read full story. Source: BBC News, 22 July 2021 -
News Article
Maternity services may struggle if Covid-19 rates surge
Patient-Safety-Learning posted a news article in News
Health professionals have warned that if Covid-19 rates continue to rise, Maternity services may struggle to keep running. The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have said home births have been cancelled amid ambulance shortages. Leah Deutsch, a senior registrar in obstetrics and gynaecology at the Royal Free Hospital in north London, has told The Independent that some women were unable to have their home births during the first and second wave of the pandemic. Read full story. Source: The Independent, 21 July 2021 -
News Article
Action yet to be taken on stillbirth independent investigation
Patient-Safety-Learning posted a news article in News
Now, almost two years after a consultation on inquests into stillbirths was delivered, the government has yet to respond. It has recently been reported by MPs that 1,000 babies die preventable deaths each year due to understaffing and a culture of blame among the maternity ward workforce. However, despite pressure from campaigners and a promise by the government that a response would come in September 2019, it is yet to be published. The Department for Health and Social Care has told Byline Times, “work on analysing the responses to the consultation on coronial investigations of stillbirths has been delayed during the COVID-19 pandemic”. Read full story. Source: Byline Times, 14 July 2021 -
News ArticleA new independent inquiry has been launched after reports of mother and baby deaths at Nottingham University Hospitals Trust. According to patient safety minister Nadine Dorries, the inquiry will be led externally and will be examining cases going back to 2016. The review has been welcomed by families but they have said they want to be fully involved in the process including setting the terms of reference and making sure it is a truly independent inquiry. Read full story. Source: The Independent, 13 July 2021
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News Article
Another maternity unit downgraded by NHS watchdog
Patient-Safety-Learning posted a news article in News
The Care Quality Commission has downgraded another maternity unit over 'blame culture' and concerns over safety. After an inspection was carried out, Salisbury Foundation Trust , which was downgraded from 'good' to 'inadequate' has been told it must make improvements after concerns were raised about safety and leadership of the maternity unit. Head of hospital inspection at the Care Quality Commission, Amanda Williams has said: “Following our recent inspection of Salisbury District Hospital’s maternity services, we found that women and babies using the service received effective care and treatment which met their needs most of the time. But most of the time is not good enough. Read full story. Source: The Independent, 10 July 2021 -
News Article
Culture of blame prevented staff admitting mistakes, report finds
Patient-Safety-Learning posted a news article in News
A new report into maternity safety has found due to a 'culture of blame' lessons haven't been learned. Jeremy Hunt, chair of the Health Committee has said 1,000 more babies a year would survive if the maternity service in England was as safe as Sweden's. Another expert report found a high incidence of brain injuries in maternity units. A new budget has been set out to help reduce the rate of stillbirths, neonatal deaths, maternal deaths and brain injuries by 2025. Read full story. Source: BBC News, 06 July 2021 -
News Article
1,000 babies die preventable death each year says a report by MPs
Patient-Safety-Learning posted a news article in News
A report by MPs has said 1,000 babies die every year as a result of lessons not being learned and blame being shifted despite a number of high profile cases involving maternity scandals. Jeremy Hunt who chairs the committee has said “Despite a number of high-profile incidents, improvements in maternity safety are still not happening quickly enough". The report also found that women from ethnic minority backgrounds are more likely to experience a higher rates of stillborn and neonatal deaths. The Department of Health and Social Care has been approached for comment. Read full story. Source: The Guardian, 6 July 2021- Posted
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News ArticleCriminal prosecution is being considered by the NHS care watchdog over the maternity scandal at Nottingham University Hospitals Trust. Many babies have died in the maternity unit due to poor patient care and failings by staff. Evidence is now being examined as to whether the trust committed a criminal offence by not following the proper procedures and by not being honest with parents and families about the deaths of the babies. Read full story. Source: The Independent, 2 July 2021
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News Article
NHS chief admits hospital was not a safe environment for mothers and babies
Patient-Safety-Learning posted a news article in News
A leaked message to NHS staff on Thursday revealed Nottingham University Hospitals Trust NHS chief Tracy Taylor, admitted that the maternity ward was not a safe environment for women and babies. In the message, it was revealed that 37 new members of staff have been hired in an attempt to help improve services. She has said: “Improving our maternity services is one of our top priorities and we know how tirelessly colleagues in maternity are working to make those improvements". Read full story. Source: The Independent, 2 July 2021 -
News Article
£2.45 million pledge to improve childbirth care
Patient-Safety-Learning posted a news article in News
2.45 million has been pledged by the government to improve childbirth care which is due to happen this year. It has been announced that the funding is intended to help NHS maternity staff to improve the safety of the women and babies they care for. Maternity safety minister Nadine Dorries said "I am determined to make sure as many mums as possible can go home with healthy and happy babies in their arms". Read full story. Source: Department of Health and Social Care, 4 July 2021 -
News Article
Nottingham maternity: Dozens of baby deaths after numerous errors made
Patient-Safety-Learning posted a news article in News
An investigation by The Independent and Channel 4 has found dozens of babies have died on the maternity wards at Nottingham hospitals as a result of poor care. The special report tells how families have not had their concerns properly investigated nor has the hospital attempted to learn from previous mistakes. Nottingham NHS is now facing dozens of clinical negligence claims by grieving families, with the trust estimated to have already paid out £91m in damages and legal costs. Read full story. Source: The Independent, 30 June 2021 -
News Article
Ethnic minorities found at higher maternity risks
Patient-Safety-Learning posted a news article in News
The charity Birthright have launched an inquiry into why women from ethnic minority backgrounds are experiencing higher maternity risks. Evidence in the inquiry will be gathered from parents, anti-racist campaigners, midwives and obstetricians. The NHS has said it is working on a new strategy to address inequalities, maternity and neonatal care. Read full story. Source: BBC News, 23 June 2021 -
News Article
£52 million investment to fast track online maternity records
Patient-Safety-Learning posted a news article in News
England's Chief Nurse has announced every pregnant woman will be able to access their maternity records from their smart phone. The move has been made so that pregnant women will be able to have more control over their pregnancy and will be able to see all the decisions and information made via a smart phone. GPs and health professionals will also be able to access this information, it is hoped that by doing so, it will mean pregnant women will no longer have to repeat information to different clinicians they see whilst pregnant, which may also help improve safety. Read full story Source: NHS England, 17 June 2021 -
News Article
Two more NHS maternity units downgraded
Patient-Safety-Learning posted a news article in News
Two more NHS maternity units have been downgraded by the care watchdog amid safety concerns. The services at Colchester Hospital and Ipswich Hospital were downgraded from good, to 'requires improvement', finding staff shortages at both hospitals. Moreover, it was also found handovers were not sufficient meaning staff were not sharing the proper information about the women and babies. Among the concerns and issues raised, there were problems with team-working, properly recording patient information, and inefficient information systems. Read full story Source: The Independent, 16 June 2021- Posted
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News Article
Covid: Stillbirth and prematurity risks may be higher
Patient Safety Learning posted a news article in News
A large UK study suggests having coronavirus around the time of birth may increase the chance of stillbirths and premature births - although the overall risks remain low. Scientists say while most pregnancies are not affected, their findings should encourage pregnant women to have jabs as soon as they are eligible. The majority are offered vaccines when they are rolled out to their age group. The study appears in the American Journal of Obstetrics and Gynecology. The research, led by the National Maternity and Perinatal Audit, looked at data involving more than 340,000 women who gave birth in England between the end of May 2020 and January 2021. Researchers say a higher risk of stillbirth and prematurity, as well as a greater chance of having a Caesarean section, remained even once factors such as the mother's age, ethnicity, socio-economic background and common health conditions were taken into account. Babies born to women who tested positive were more likely to need special neonatal intensive care because they were born early and needed more support - rather than being infected with coronavirus itself. Professor Asma Khalil, co-author of the paper, said it was important for women and healthcare workers to be aware of the potential risks. Read full story Source: BBC News, 21 May 2021 -
News Article
Baby death raises questions over maternity care
Patient Safety Learning posted a news article in News
Beth and Dan Wankiewicz want answers about why their baby son Clay died last year, shortly after his birth at Doncaster Royal Infirmary. Despite a low-risk pregnancy, the family say Clay died from multiple skull fractures. Doncaster and Bassetlaw NHS Foundation Trust said "the provision and delivery of high-quality" care is a priority. The BBC has found a 2016 review flagging concerns about the hospital's maternity care was never published. The report - one of scores of unpublished reports discovered by a Freedom of Information request by BBC's Panorama programme - highlighted significant patient safety concerns. Beth Wankiewicz was admitted to hospital last July, but after a day of labour her baby had still not been born. With no consultant doctor on site, a junior doctor made two attempts to deliver the baby with forceps, after getting advice on the phone. Father, Dan, remembers the second attempt with forceps being much more vigorous "which was a bit of a shock". The family say there was a further delay before they had a Caesarean section. Their baby had to be pushed back up the birth canal into the womb for the C-section to be performed. "I think after about 10 minutes, we both looked at the clock, and we said it's not looking good," said Dan. Around 20 minutes after their son was born, despite attempts to resuscitate him, they were told he had died. The following day they say a midwife told them she was being pressurised by other staff to say Clay had been stillborn, but she was sure he had been born alive, and she had heard a heartbeat. The family now believe this was to avoid scrutiny and the need for a coroner's inquest, which doesn't happen with still births. Read full story Source: BBC News, 19 May 2021- Posted
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EventuntilThis free to attend webinar is being delivered by BAPM in partnership with the Healthcare Safety Investigation Branch (HSIB) to support the launch of the revised framework for practice on newborn infants who suffer a sudden and unexpected postnatal collapse (SUPC). Speakers will provide an overview of the new framework, cover ways to support good practice and reduce the risk of SUPC. This webinar is aimed at perinatal professionals who care for babies in hospital in the first week after birth as well as parents. Programme: The Parent Story Introduction to the new framework The SUPC Risk Reduction Pathway Investigating and Managing the Baby after a SUPC Questions Chair: Louise Page, Deputy Clinical Director of Maternity Investigation Programme, HSIB Speakers: Sarah Land, Charity Manager, PEEPS HIE Charity Julie-Clare Becher, Consultant Neonatologist, Simpson Centre for Reproductive Health, Edinburgh Esther Tylee, Infant Feeding Lead Midwife, Bedford Hospital NHS Trust Francesca Entwistle, Deputy Programme Director (Advocacy), UNICEF UK Baby Friendly Initiative Rachel Walsh, National Neonatal Clinical Fellow, NHS Resolution Register
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EventuntilThis event will mark the 2021 World Health Organisation’s World Patient Safety Day and aims to showcase the patient safety work happening in the NHS and with partners, to improve the safety of maternal and neonatal care. Speakers: Introduction from Aidan Fowler, National Director of Patient Safety (chair) Presentations from the National Maternity Champions, Matthew Jolly, National Clinical Director for Maternity and Women's Health and Professor Jacqueline Dunkley-Bent OBE, Chief Midwifery Officer Hear from AQUA (the Advancing Quality Alliance) about its safety culture programme for maternity and neonatal board safety champions Dr Nicola Mackintosh, Associate Professor in Social Science Applied to Health, SAPPHIRE Deputy, University of Leicester will present on ‘What a good maternity safety culture looks like’, providing an overview of a considered analysis of maternity and neonatal safety culture surveys Tony Kelly, National Clinical Lead for the Maternity and Neonatal Safety Improvement Programme will provide an introduction to the national Maternity Early Warning Score (MEWS) tool and Newborn Early Warning Trigger and Track (NEWTT) Expected Audience: NHS provider and commissioning staff, particularly those working in maternity and neonatal care and in patient safety roles. Register
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Event
The NHS maternity scandal: Inside a crisis
Patient Safety Learning posted an event in Community Calendar
At a time when the NHS is struggling unprecedently, having been battling a pandemic for 18 months, one of the most concerning areas is the state of maternity services at trusts around the country. It has been uncovered following recent investigations by the Independent newspaper's health correspondent Shaun Lintern that the scale of the problem is putting the lives of both mothers and babies at risk on a daily basis. To explore the apparent crisis existing within our hospitals Shaun will be hosting a live panel discussion with maternity experts who have experience of the situation from within the NHS as well as elsewhere. The speakers will help explain what has gone so wrong, what impact it has had and what lasting effects there might be, as well as what the future holds and if the scandal has at least ensured improvements are now in place and our maternity services are becoming safer for all who use them. The panel will include Donna Ockenden, the chair of Shrewsbury inquiry and Senior Midwifery Adviser, Gynaecologists president Edward Morris and James Titcombe, OBE and ambassador for charity Baby Lifeline; Associate Editor, Journal of Patient Safety and Risk Management and campaigner who helped expose poor care at University Hospitals Morecambe Bay Trust following the death of his son Joshua. Register -
Content ArticleThe maternity services at the Royal Devon and Exeter NHS Foundation Trust share their infographic which informs their staff of the 15 Immediate and Essential Actions from the Ockenden report and the action plan needed to implement these.
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