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Found 554 results
  1. News Article
    Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020
  2. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  3. Content Article
    A report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS.
  4. News Article
    Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth. The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth. Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life. In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage. The new funding will also cover the final year of the independent investigation into the Shrewsbury trust. Read full story Source: The Independent, 26 November 2020
  5. News Article
    Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler. Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation. Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong. The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes. Read full story Source: The Independent, 24 November 2020
  6. Content Article
    The COVID-19 pandemic provides new challenges for the safety of people receiving and providing maternity care. This project, conducted in collaboration with the PROMPT Maternity Foundation and THIS.institute, involved a rapid-response consultation exercise to understand what good looks like for managing obstetric emergencies in women with suspected or confirmed COVID-19.
  7. News Article
    A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020
  8. News Article
    A coroner has urged ministers to revisit plans to make it possible to hold inquests into babies that are stillborn after a baby died due to “excessive force” during an attempted forceps delivery. Senior coroner Caroline Beasley-Murray has written to the Ministry of Justice after she was forced to stop hearing evidence into the death of baby Frederick Terry, known as Freddie, who died under the care of the Mid and South Essex Hospitals Trust on 16 November, last year. An inquest into his death was started in September where Freddie was found to have died after suffering hypovolaemic shock as a result of losing a fifth of his blood when his skull was fractured during a traumatic birth attempt. In a report on the case the coroner said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts." "The evidence showed that baby Freddie's very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby." The coroner said the injuries he sustained implied “an excessive degree of force” in the application of the forceps, which are curved metal instruments that fit around a baby’s head and are designed to help deliver the baby. The inquest had to be stopped from hearing any more evidence because coroners are not able to investigate stillborn babies. As part of her report, the coroner said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. "Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, the Government issued a consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.” Read full story Source: The Independent, 17 November 2020
  9. News Article
    Mothers are being needlessly separated from their babies under strict hospital restrictions introduced to stop the spread of COVID-19, doctors and charities have warned. The measures preventing UK parents from staying with their babies when one or both require hospital treatment are causing trauma and increasing the risk of physical and mental health problems, it is claimed. Some parents of sick babies are also being barred from seeing their child in neonatal units, which is causing distress and preventing bonding. Campaigners have written to the health secretary, Matt Hancock, to raise their concerns. They want hospitals to review these policies urgently and have called for a working group to draw up national standards to meet families’ needs during pregnancy, birth and breastfeeding. Read full story Source: The Guardian, 16 November 2020
  10. Content Article
    In this blog by the British Society of Criminology, Sharon Hartles critically examines the journey so far towards the implementation of the remaining eight recommendations set out in the landmark publication of the Medicines and Medical Devices Safety Review First Do No Harm report in July 2020.
  11. News Article
    Lockdown measures in England led to thousands fewer children receiving vital immunisations for a range of diseases include measles, diphtheria and whooping cough, Public Health England (PHE) has warned. PHE has warned parents they should continue to get their children immunised regardless of lockdown and restrictions brought on by coronavirus. During the first wave of coronavirus the government advised that children should continue to receive vaccinations as scheduled but despite these some appointments were delayed and the numbers of children vaccinated against common diseases fell compared to 2019. PHE looked at data from almost 40% of GP surgeries for use of the common 6-in-1 vaccination for diseases including diphtheria, tetanus, whooping cough, and polio as well as uptake of the measles, mumps and rubella (MMR) vaccine to 19 October. In total 167,322 children had the 6-in-1 vaccine, a drop of 6,600 on the same period in 2019, a fall of almost 4%. A total of 167,670 children had the MMR jab, 4,700 fewer than in 2019, a drop of 2.8%. Although the vaccinations recovered after lockdown the rates are still lower overall than 2019. Dr Mary Ramsay, head of immunisations at Public Health England, said: “Vaccines remain the best defence against infection. It’s essential we maintain the highest possible uptake to prevent a resurgence of serious and sometimes life-threatening diseases. “Routine vaccinations are still available throughout the pandemic – it’s vital that we continue to make it as easy and safe as possible for parents to take their children to appointments.” Read full story Source: The Independent, 11 November 2020
  12. Content Article
    Identifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk. 
  13. News Article
    A nurse is due in court charged with eight counts of murder following an investigation into baby deaths at the Countess of Chester hospital neonatal unit in Cheshire. Lucy Letby, 30, is due to appear at Warrington magistrates court on Thursday. She was arrested for a third time on Tuesday as part of the investigation into the hospital, which began in 2017. A force spokesman said: “The Crown Prosecution Service has authorised Cheshire police to charge a healthcare professional with murder in connection with an ongoing investigation into a number of baby deaths at the Countess of Chester hospital.” He said Letby was facing eight charges of murder and 10 charges of attempted murder relating to the period from June 2015 to June 2016. On Tuesday, police said parents of all the babies involved were being kept fully updated on developments and were being supported by officers. Read full story Source: The Guardian, 11 November 2020
  14. Event
    This Westminster Health Forum conference will discuss the priorities for improving the health outcomes in babies and young children and the next steps for policy. It is taking place as The Rt Hon Andrea Leadsom MP, Government's Early Years Health Adviser - who is a keynote speaker at this conference - leads a review into improving health outcomes in babies and young children as part of the Government’s levelling up policy agenda. With the first phase of the review expected in early 2021, this conference will be an opportunity for stakeholders to discuss the priorities and latest thinking on improving health outcomes. The discussion is bringing together stakeholders with key policy officials who are due to attend from DHSC and the DfE. The agenda: The priorities for improving health outcomes for babies and young children. Understanding the importance of the first 1,000 days in child development' Improving child public health, reducing inequalities and the impact of social adversity in childhood. Identifying measures for supporting vulnerable and disadvantaged young children and families - and learning from the COVID-19 pandemic. Priorities for system-wide collaboration to address underlying health inequalities and key opportunities for improving health outcomes in young children going forward. Next steps for the commissioning of health services for children in the early stages of life. Improving health outcomes for young children across health and care - integrating services, care pathways, workforce training, and partnership working. Register
  15. Content Article
    Obstetric quality of care measures have largely focused on severe maternal morbidity (SMM), with little consensus about measures of less severe but more prevalent delivery and neonatal complications. This study, published in The Joint Commission Journal of Quality and Safety, analyses risk-adjusted maternal and neonatal outcomes using both ICD-10 coding and electronic health record (EHR) data.
  16. News Article
    A national review has been launched by regulators because of an increased number of stillbirths during the first wave of covid, HSJ can reveal. The Healthcare Safety Investigation Branch (HSIB) is investigating 40 intrapartum stillbirths which took place between April and June this year, when the country experienced the first wave of COVID-19. During the same three months in the previous year, 24 stillbirths were reported to HSIB. The HSIB has told HSJ it has now launched a thematic review into the stillbirths, which will investigate stillbirths in all settings across England during that time period. The Royal College of Obstetricians and Gynaecologists, which has also launched a national review into perinatal outcomes during the pandemic, estimates that 86 per cent of maternity units reported a reduction in emergency antenatal presentations in April, “suggesting women may have delayed seeking care”. HSIB is aiming to complete the thematic review early next year. It said the stillbirths being investigated are not concentrated on any geographical area or trust. Read full story (paywalled) Source: HSJ, 2 November 2020
  17. News Article
    Poorer mothers are three times more likely to have stillborn children than those from more affluent backgrounds, according to a new study. The wide-ranging research, conducted by pregnancy charity Tommy’s, also found that high levels of stress doubled the likelihood of stillbirth, irrespective of other social factors and pregnancy complications. Unemployed mothers were almost three times more at risk. The government has been urged to take immediate action to address the social determinants of health and halt the rise in pregnant women who face the stress of financial insecurity. Researchers said getting more antenatal care can stop women from having a stillbirth — with mothers who went to more appointments than national rules stipulate having a 72% lower risk. Ros Bragg, director of Maternity Action said, “If the government is serious about combatting stillbirths, it must address the social determinants of health as well as clinical care. Women need safe, secure employment during their pregnancy and the certainty of a decent income if they find themselves out of work. It is not right that increasing numbers of pregnant women are dealing with the stress of financial insecurity, putting them at increased risk of serious health problems, including stillbirth.” Read full story Source: The Independent, 29 October 2020
  18. Content Article
    Learning about healthcare safety often focuses on understanding what has gone wrong, but it is just as important to examine what good looks for safety in maternity units. In this blog, Elisa Liberati describes how she worked with a team and several collaborators to develop a framework describing 7 key features of safety in maternity units. To ensure the study was as rigorous as possible, they combined several different methods and worked in a highly collaborative way across the system. Follow the link below to read the full blog, published by THIS.Institute.
  19. News Article
    A hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff. Jenny Feasey, from Heysham in Lancashire, is still coming to terms with the loss of her son Toby who was stillborn at the Royal Lancaster Infirmary, part of the University Hospitals of Morecambe Bay Foundation Trust in January 2017 after a series of mistakes by staff who did not act on signs she had pre-eclampsia. Jenny, 33, has backed The Independent’s campaign for improved maternity safety and called on midwives to learn lessons after what happened to her family. She added: “This was an easily avoidable situation. They just didn’t piece it together, all they had to do was carry out a test and I lost my son because of it." Read full story Source: The Independent, 25 October 2020
  20. News Article
    Parents and professionals have been devastated by the impact of the pandemic on some of the UK’s most vulnerable patients Kelly Stoor gave birth to her daughter, Kaia, 14 weeks early. On 12 March, the midwife held her up for Kelly to see before whisking Kaia off to the neonatal unit for critical care. Kaia became seriously ill and was transferred to a hospital in Southampton, 50 miles away from home, for specialist treatment just before lockdown was imposed on 23 March. While there, she teetered on the edge of life and death for weeks and underwent life-saving surgery twice. The impact on Kelly, her husband, Max, and their other three children has been enormous. Hospital restrictions in April dictated that only one parent was allowed to visit. Both parents were not able not hold their daughter for the first time until 88 days after she was born. “It was extremely difficult,” says Kelly. “I wasn’t allowed to hold her because of Covid. I had to wear gloves if I was going to touch her. We didn’t know if she was going to make it, and Max and I weren’t allowed in together to be with her. There was one time I was with her for three hours and I couldn’t cope any more. I wanted to break.” Kelly is not alone. In the UK, at least 25,000 children are living with conditions that require palliative care support and their lives, along with those of their families, have been upended by the coronavirus pandemic and accompanying restrictions. A report by Rainbow Trust found that lockdown was a distressing experience for many; 80% of those surveyed by the charity in April said their situation was worse or much worse than before lockdown. Nearly 60% of parents, meanwhile, say that their mental health is worse than before the pandemic. Families have had to take on the strain of caring full-time for a child with a life-limiting illness, such as cancer or neurological conditions, with little to no support. There has been no respite, explains Dr Jon Rabbs, a consultant paediatrician and trustee for Rainbow Trust. When lockdown was announced, many community healthcare services had to stop face to face contact and special schools which supported children were also closed. “One of my families is at breaking point, they are so exhausted and worried,” he says. In child healthcare there have been delays, he says. Urgent treatment is always available but follow-up care has been cancelled or delayed in some places. “In my practice we have not missed any significant relapses,” he adds. “But imagine the worry not knowing whether things were going to be OK or not.” Read full story Source: The Guardian, 22 October 2020
  21. News Article
    The parents of a three-year-old boy whose death was part of an alleged NHS cover-up have won a six year battle for the truth about how he died. Shropshire coroner John Ellery backed the parents of three-year-old Jonnie Meek in a second inquest into his death on Thursday and rejected evidence from nurses about what happened at Stafford Hospital in August 2014. Jonnie, who was born with rare congenital disability De Grouchy syndrome, died two hours after being admitted to hospital to trial a new feed which was being fed directly into his stomach. His parents, John Meek and April Keeling, from Cannock in Staffordshire, have always maintained their son died after a reaction to the milk feed caused him to vomit and suffocate. But they have been forced to battle what they believe was an attempt to hide what happened after they discovered attempts to alter their son’s medical history with claims he had experienced several cardiac arrests requiring resuscitation which never happened. In 2015, healthcare assistant Lauren Tew, who was with Jonnie and his mother when he died, told the HSJ that a statement in her name submitted to a child death overview panel stating Jonnie had died from a sudden cardiac arrest was false and she had never made such a statement. Another statement said Jonnie had been admitted to hospital for three weeks months before his death which also never happened. After his parents exposed the false statements an independent inquiry was launched, with three independent experts agreeing with Jonnie’s parents, and in April last year the High Court quashed the original inquest verdict that Jonnie died of natural causes and pneumonia. Speaking to The Independent Jonnie’s father said: “This does bring us some peace after six years. For the coroner to say he believes April over the nurses after all this time is a big weight lifted off her. “The hospital definitely decided to try and cover up what happened to Jonnie. We have always said we knew what happened and this has been a massive waste of resources. I am still very concerned about how these things can happen in the first place.” Read full story Source: The Independent, 15 October 2020
  22. Content Article
    In this guest blog for mumsnet, Nadine Montgomery talks about her journey to the Supreme Court to cement patients’ right to make an informed decision. Nadine highlights the lack of information she was given around potential birth risks as a diabetic pregnant women and how, if better informed, she would have made different choices which could have prevented her baby from suffering harm.
  23. Content Article
    This is a video recording of a formal meeting (oral evidence session) of the Health and Social Care Select Committee on Tuesday 29 September 2020, as part of their inquiry looking at the Safety of maternity services in England.
  24. News Article
    Too many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said. He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies. “Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.” Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.” Read full story Source: The Guardian, 29 September 2020
  25. Content Article
    Lockdown has been a seismic shock for every family and community. Sadly, the voices of the hardest hit have been heard the least. This report sets about to change this by exploring pandemic and lockdown reflections from a diverse group of expectant and new parents during the critical first months and years of their babies’ development. Charities Best Beginnings, Home-Start UK and Parent-Infant Foundation were alarmed that the voices of parents with new babies have been absent from key pandemic responses. As a result, they worked with Critical Research to survey 5,000 new and expectant parents on their lockdown experiences and found a mixed picture, shining a light on huge disparities between different families and communities.
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