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Content ArticleLearning 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.
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Content ArticleIn 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.
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Content ArticleThis 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.
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Content ArticleLockdown 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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Neonatal herpes simplex virus (HSV) disease, also called 'neonatal herpes' or 'neonatal HSV', is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. It is caused by the herpes simplex virus (HSV), the same virus that causes cold sores and genital infections. HSV infections are incredibly common in older children and adults and typically cause mild symptoms, or often no symptoms at all. There are some simple things you can do to help prevent babies from catching herpes infections. These include regular hand washing, covering cold sores and not kissing babies who are not your own. Click on the link below to find out more about neonatal herpes and how to keep your baby safe. -
Content Article
Maternity and neonatal safety champions toolkit
PatientSafetyLearning Team posted an article in Maternity
This toolkit provides information and resources that will help maternity and neonatal safety champions to develop strong partnerships, promote positive professional cultures, and support the delivery of the safest care possible through best practice. Content includes: National maternity safety ambition Role of the Safety Champion How to support safer maternity care National support offer Further resources. -
Content ArticleThis report represents the findings of the fourth perinatal confidential enquiry carried out as part of the MBRRACE-UK programme of work and focuses on stillbirths and neonatal deaths in twin pregnancies. It contains illustrative vignettes which are taken from real life events. The vignettes are used to illustrate single aspects of care and are not intended to describe all the care provided to individual mothers and their babies. The vignettes are often a combination of events from the care of more than one mother and her babies and are described such that it is not possible to identify the individuals involved. The report sets out many key findings and recommendations based on different stages and aspects of care.
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Content ArticleThis blog, published on the Maternity Experience website, is written by Gill Phillips Director of Nutshell Communications Ltd and creator of the Whose Shoes?® concept and principles. Through her facilitation work, Gill helps people get to the heart of what is important in communication and co-production. Instead of wrapping things up in jargon and complicated language, messages are honest, direct and simple, sourced from what real people are saying. In this blog, Gill talks about the networks that have come together over the past year to explore baby loss and how this work is enabling diverse conversations, rich discussions and a shared commitment to continue improving services for families who experience bereavement.
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'Continuity of carer' in midwifery is when a woman has consistency in who they see during their pregnancy, labour and postnatal period. In this video, three midwives share their experiences of working in this way and talk about the benefits they've seen for women, babies and their own practice. They provide examples of how this model can improve the safety of services and offer advice for teams and individuals embarking on the continuity of carer journey. -
Content ArticleMothers and families whose baby was born at an NHS hospital after 1st April 2017 and who may be concerned that their baby sustained a brain injury at birth may be going through an investigation process. This guide, from Action Against Medical Accidents (AvMA), provides mothers and families with information about the process.
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Content ArticleThis self-help guide contains useful information for parents or guardians who are acting on behalf of babies or children who have been affected by avoidable harm in healthcare. If you have any further questions, please visit the Action Against Medical Accidents (AvMA) website where you will find more advice and a range of specialised self-help guides. Or you can call their helpline on 0845 123 2352.
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Content ArticleThe Royal College of Obstetrics and Gynaecology (RCOG) has guidance on group B Strep infection in newborn babies, which was last updated in September 2017. A national learning published earlier in 2020 by the Healthcare Safety Investigation Branch (HSIB) highlighted that the RCOG guidance was not being followed. This report from the Group B Strep Support reinforces these findings. Only a tiny number of NHS Trusts are following the key new recommendations around giving pregnant women information on group B Strep, offering testing to some pregnant women, and following Public Health England guidelines on testing for group B Strep. As a result, pregnant women face a postcode lottery, potentially receiving significantly different care from recommended practice. Group B Strep Support recommends that the NHS prioritises the prevention of group B Strep infection in newborn babies. A key step towards this would be to ensure published national guidance from recognised expert bodies is adopted and implemented in a timely manner.
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Content ArticleNewborn babies may need extra care in a neonatal intensive care unit or special care baby unit if they were born prematurely or if they need care for a particular health condition. Babies and infants that need long-term care can be transferred to a local unit or discharged to receive care at home. A baby with complex health needs may move between distinct areas of care or 'pathways'. This Care Quality Commission (CQC) review looked at how risks for newborn babies are identified and managed and at the care for infants in the community who need respiratory support. This review draws on one particular case that had a tragic outcome for a baby and her parents. Elizabeth Dixon was born prematurely but suffered brain damage as a result of missed high blood pressure. She died shortly before her first birthday in 2001, when there was a failure to correctly maintain her tracheostomy tube. While this review was not an investigation of the specific circumstances of Elizabeth's case, it drew on this to examine current practice, systems and guidance.
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Content ArticleThis report summarises the impacts on babies of COVID-19 and the spring 2020 national lockdown. The report also explores how local systems responded to the challenges presented by COVID-19. It seeks to understand the factors that have shaped the response by services that support babies and their families. Most importantly, the report seeks to ensure that lessons are learnt for the future of service provision for this age group.
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Content ArticleFollowing the publication of Donna Ockenden’s first report: Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust on 11 December 2020, the NHS has issued this latest update. Read previous letter update
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Content ArticleRecent work has emphasised the benefits of patient-physician concordance on clinical care outcomes for underrepresented minorities, arguing it can boost communication and increase trust. Authors of this study explored concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn-physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. They found no significant improvement in maternal mortality when birthing mothers share race with their physician. You can also read the news coverage in the Washington Post here. To access the research, follow the link below.
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Content ArticleThe Early Notifcation scheme is a national programme for the early reporting of infants born with a potential severe brain injury following term labour to NHS Resolution. This leaflet has been produced as an overview to highlight the: key findings of the report six recommendations information on our collaborative partners and other resources available on our website including information on supporting staff and families.
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Content Article
NHS Resolution: Neonatal jaundice (19 October 2018)
Patient Safety Learning posted an article in Maternity
Neonatal jaundice is a common condition which is usually harmless, requires no treatment or responds to phototherapy. On rare but tragic occasions it can cause long-term brain damage with physical and psychological consequences for the family, or death. NHS Resolution reviewed twenty claims for injury secondary to neonatal jaundice which were notified to NHS Resolution between 2001 and 2011 and identified key themes and most common risk factors. -
Content ArticleNeonatal herpes simplex virus (HSV) disease is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. Early recognition and treatment of the virus has been shown to significantly improve babies' chances of making a full recovery. Kit Tarka Foundation works to prevent newborn baby deaths; primarily through raising awareness of neonatal herpes, funding research and providing advice for healthcare professionals and the general public.
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Content ArticleA 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.
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COVID-19: managing an obstetric emergency (November 2020)
PatientSafetyLearning Team posted an article in Maternity
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. -
Content ArticleSarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
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Content Article
Postnatal Risk Assessment Matrix (PRAM)
PatientSafetyLearning Team posted an article in Maternity
This Postnatal Risk Assessment Matrix (PRAM) resource was developed by Dr Cindy Shawley, Quality Improvement Lead for Maternity at Hampshire Hospitals NHS Foundation Trust. The pack includes a number of monitoring and assessment tools to help keep mums and babies safe. The following two sections have been selected for the finals of the Nursing Times Awards, under the Patient Safety category: The First Hour of Care: Keeping mums and babies together (a proforma and pathway to promote normal adaptation to life) Holding your baby safely poster (as referenced in the recent National Learning Report, Neonatal collapse alongside skin-to-skin contact) Please open the attached documents to view the full PRAM resource pack as well as the two award-nominated sections that can be downloaded independently. Many thanks to Dr Shawley for giving permission to share these important patient safety resources on the hub. -
Content ArticleClinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. Clinical governance encompasses quality assurance, quality improvement and risk and incident management. These guidelines cover responsibilities, programme standards and performance monitoring, quality assurance, quality improvement, and risk and incident management.
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Content Article
National Learning Reports offer insight and learning about recurrent patient safety risks in NHS healthcare that have been identified through HSIB investigations. They present a digest of relevant, previously investigated events, highlight recurring themes and, where appropriate, make safety recommendations. National learning reports can be used by healthcare leaders, policymakers and the public to aid their knowledge of systemic patient safety risks and the underlying contributory factors, and to inform decision making to improve patient safety. The Healthcare Safety Investigation Branch (HSIB) Summary of themes arising from HSIB maternity investigation programme report (March 2020) describes eight themes arising from the maternity investigations. Sudden unexpected postnatal collapse (SUPC) was identified as a theme for further exploration in order to highlight areas of system-wide learning. SUPC is a rare but potentially fatal event in otherwise healthy appearing term (born after 37 completed weeks) newborn babies at birth. Between April 2018 and August 2019 HSIB completed 335 maternity investigations. Of the 12 identified SUPC cases, there were 6 cases where positioning of the baby to achieve skin-to-skin contact may have contributed to SUPC. While the number of incidents found was small compared to the number of term babies who had skin-to-skin contact at birth these incidents may in future be avoided and so learning is essential.
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