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Content Article
Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.- Posted
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Content ArticleThis guideline describes good patient experience for babies, children and young people, and makes recommendations on how it can be delivered. It aims to make sure that all babies, children and young people using NHS services have the best possible experience of care. It includes recommendations on: overarching principles of care communication and information planning healthcare consent, privacy and confidentiality advocacy and support improving healthcare experience, including healthcare environments accessibility, continuity and coordination
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Content Article
Considering Valproate video (February 2022)
Patient-Safety-Learning posted an article in Medication
Sodium valproate is a medication used to treat epilepsy, bipolar disorder and migraines, but it can cause birth defects, learning disabilities and developmental problems in babies if taken during pregmamcy. This video by Central and North West London NHS Foundation Trust discusses the various effects of using valproate, including the potential harmful effects the medication can have on unborn foetuses. It features a conversation between a pharmacist and patient discussing the need for a valproate pregnancy prevention programme if the patient is to be prescribed valproate. -
Content ArticleOn 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
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HypoBaby blog - The beginning… Diagnosis (20 August 2018)
Patient-Safety-Learning posted an article in Diabetes
The HypoBaby blog is written by the parents of Noah, a young boy who was diagnosed with type 1 diabetes as a baby. In this post, they describe Noah's diagnosis and why it took so long to work out that it was diabetes causing his symptoms. Noah ended up in diabetic ketoacidosis (DKA) and needed emergency treatment. They highlight the importance of being aware of the symptoms of type 1 diabetes, stating that if they had been aware of the symptoms, he may have been diagnosed sooner. -
Content ArticleMaternity costs make up the largest cost to the NHS in value of claims. The Early Notification Scheme provides a faster and more caring response to families whose babies may have suffered severe harm. 'The second report: The evolution of the Early Notification Scheme' provides an overview of progress made since the report into the first year of the scheme, which was published in 2019. The report updates on the progress of the key recommendations which were made in the first report and reflects on modifications and improvements made to the scheme since its launch five years ago. It provides an analysis of the main clinical themes, based on a small cohort of cases, and makes recommendations to further improve outcomes for affected families.
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Content ArticleIn this BMJ feature, journalist Emma Wilkinson looks at how a shortage of health visitors in England is leaving babies and children exposed to safeguarding risks, late diagnosis and other problems. An estimated third of the health visitor workforce has been lost since 2015, and research by the Parent-Infant Foundation suggests that 5000 new health visitors are needed. Families are not getting the minimum recommended number of contacts with health visitors during the first three years of life, and research into the impact of this on children's outcomes is ongoing. Emma speaks to different mothers, including Phillippa Guillou, who had a baby in 2020 and struggled to breastfeed. Philippa felt unsupported and ignored by her local health visiting service, who only saw her once by videocall when her baby was one year old.
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Content ArticleThis debate begins with a statement by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, regarding the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust. It is followed by questions from MPs in the chamber and the Minister's responses.
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Content ArticleReports showing that babies and mothers died or were harmed as a result of failures by, and sometimes heartless cruel treatment in, NHS maternity units are becoming worryingly common. Dr Bill Kirkup’s just-published 192-page exposé of an appalling catalogue of failings at East Kent NHS trust between 2009 and 2020 is the second in the last 12 months. As many as 45 babies and 23 mothers in East Kent died avoidably during that time because their care was substandard, his inquiry found. March brought Donna Ockenden’s grim findings about poor maternity care at the Shrewsbury and Telford trust. And Kirkup produced the first detailed exposition of what inadequate care of women and their offspring during childbirth looked like when in 2015 he laid bare “serious and shocking” lapses in care at Morecambe Bay trust. A fourth official inquiry, again being led by Ockenden, is under way into death, brain damage and other horrendous outcomes at the Nottingham trust. Families affected claim that, despite coroners’ findings, close scrutiny of the trust by regulators, media coverage of lapses in care and pressure for change, “babies, mothers and their families continue to be harmed”. No wonder Rob Behrens, the NHS Ombudsman, says: “The phrase ‘never again’ is starting to ring hollow.”
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Content ArticleThis is a written statement to the House of Commons by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, on behalf of the UK Government. It regards the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust.
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In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.- Posted
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Content ArticleMBRRACE-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 1 January and 31 December 2020.
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Content ArticleA fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry.
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Content ArticleThis article tells the story of Baby E, who died two hours after delivery following issues with the management of her labour. The maternity unit was short-staffed on the night of Baby E's birth and there were delays in getting her mother to theatre for a caesarean section. Baby E's parents felt that the hospital withheld information from them, failing to inform them of internal investigations that had taken place following Baby E's death. At the inquest, the coroner concluded that errors had been made, including the fact that Baby E's low heart rate had been missed. She also criticised the decision-making process in the management of labour, but concluded that she was unable to say whether this had made a difference to whether or not Baby E lived.
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Content ArticleThis article tells the story of Ruth, whose baby son was left with severe cerebral palsy and several other injuries following oxygen starvation during his birth. Ruth's labour was badly mismanaged and she found gaps, omissions and additions to her medical notes when she requested copies. Following a lengthy legal case, Kate received compensation that allowed her family to pay for her son's medical and care needs and adapt their home.
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AvMA case study: Lyndsey's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control. -
Content ArticleThis article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
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Content ArticleThis report by Best Beginnings, Home-Start UK and the Parent-Infant Foundation highlights the impact Covid-19 and measures introduced to control its spread have had on babies. It highlights a “baby blindspot” in Covid-19 recovery efforts and a shortage of funding for voluntary sector organisations and core services like health visiting to offer the level of support required to meet families’ needs. The authors of the report spoke to mothers of babies born during the pandemic and surveyed professionals and volunteers who work with babies and their families.
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Content ArticleInfant mental health describes the social and emotional wellbeing and development of children in the earliest years of life. It reflects whether children have the secure, responsive relationships that they need to thrive. However, services supporting infant mental health are currently limited; only 42% of CCGs in England report that their CAMHS service will accept referrals for children aged 2 and under. This briefing by the Parent-Infant Foundation is aimed at commissioners looking to set up specialist infant mental health support.
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Content ArticleInsufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalisations for jaundice/hyperbilirubinaemia, hypernatraemia/dehydration, and hypoglycaemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide.This article argues that modern misconception of exclusive breastfeeding as natural and thus safe causes common and preventable harm to neonates. This review shows that the evidence regarding common and preventable harm to neonates associated with breastfeeding insufficiencies is sufficient to warrant fundamental changes to early infant feeding policies and practices.
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EventThis 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
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Content ArticleIn 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.
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Content ArticleIdentifying 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.
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Content ArticleObstetric 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.
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Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
