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Baby died after hospital’s ‘catalogue of failings’, NHS inquiry finds
Clive Flashman posted a news article in News
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 -
News ArticleA 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
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Troubled maternity wards still jeopardising patients, watchdog warns
Patient Safety Learning posted a news article in News
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- Posted
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Folic acid to be added to UK flour to help prevent birth defects
Patient Safety Learning posted a news article in News
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- Posted
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Healthy baby terminated by hospital in mix-up with sick twin
Patient Safety Learning posted a news article in News
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- Posted
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Hospital admits liability for baby’s death after ignoring mother’s concerns
Patient Safety Learning posted a news article in News
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- Posted
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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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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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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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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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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 -
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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 -
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£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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