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Content Article
Consent: The Montgomery Ruling (2015)
Claire Cox posted an article in Consent issues
The Montgomery case in 2015 was a landmark for informed consent in the UK. Nadine Montgomery, a diabetic woman and of small stature, delivered her son vaginally; her son experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby's size was a potential problem. Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section The Supreme Court of the UK announced judgement in her favour in March 2015. It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told. This ruling means that patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics -
Content Article
Each baby counts: Aims and objectives
Claire Cox posted an article in Maternity
In the UK, each year over 1000 babies die or are left with severe brain injury, not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The Royal College of Obstetricians and Gynaecologists does not accept that all of these are unavoidable tragedies, and with the Each baby counts project, they are aiming to reduce this unnecessary suffering and loss of life by 50% by 2020. -
Content ArticleMaternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, this study from THIS.Institute focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.
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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 ArticleConcern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
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Content ArticlePresentation from Mandy Townsend, Associate Director Patient Safety and co-lead for North West Coast Patient Safety Collaborative, at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticleReporters in the US from the Houston Chronicle and NBC News spent nine months examining more than 40 cases and spoke with more than 100 attorneys, doctors and current and former state employees. Their reporting reveals that some doctors have diagnosed child abuse with a degree of certainty that critics say is not supported by science. This article, the first in a series, was published in partnership with NBC News.
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Content ArticleThis investigation was prompted by evidence given to the Bristol Royal Infirmary Inquiry which spoke of the benefits of retaining hearts for the purpose of study and teaching and identified Alder Hey as holding the largest collection. Previously, the Director of the Association of Community Health Councils had expressed concerns about contraventions of the Human Tissue Act 1961 to the then Secretary of State for Health.
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Content ArticleThe Inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary.
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Content ArticleOperative vaginal birth is a common procedure used to expedite birth after full cervical dilatation where there is a clinical need to do so (15% of births in the UK in 2016). The acquisition of skills for operative vaginal birth is dependent on the exposure of junior obstetricians to situations in which they can undertake directly supervised learning.
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Content ArticleThis report by NHS Resolution provides an in-depth examination of these rare but tragic incidents and the investigations that follow them. For the purposes of this study they focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established. Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents. The study draws upon the unique data set NHS Resolution holds to address two key areas for improvement: training to prevent future incidents and the quality of serious incident investigations.
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Content ArticleThis case story is based on real events; NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff.
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Content ArticleThe RCNi (the publishing company of the Royal College of Nursing) have brought together a selection of their most popular articles on the topic of sepsis from across their journals to inform your practice. Sepsis remains a significant cause of death – it is estimated that 44,000 people die from ‘the silent killer’ every year. RCNi has a wide range of resources available to help nurses improve diagnosis and early management of the condition.
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Content ArticleA three-year programme launched in February 2017 to support improvement in the quality and safety of maternity and neonatal units across England - formerly known as the Maternal and Neonatal Health Safety Collaborative. NHS Improvement aim to: improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England contribute to the national ambition, set out in Better Birthsopens in a new window of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020.
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Content ArticleInfants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. This toolkit, produced in the US, includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.
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Content ArticleToolkit for improving perinatal safety helps hospital labour and delivery units in the US improve patient safety, team communication, and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse events resulting from poor communication and system failures.
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Content Article
Video of a Schwartz round
Claire Cox posted an article in Good practice
In 2017, The Point of Care Foundation made a film of a Schwartz round at Ashford and St Peter’s Hospitals NHS Trust. The full session lasted one hour – this is an edited version which aims to show what happens in a round. Schwartz rounds often tackle difficult emotional situations. This film deals with a particular case about a sick baby, which some viewers may find upsetting. -
Content ArticleThe creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries. The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019. The ME reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21. A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety.
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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 ArticleThe NHS Innovation Accelerator supports the uptake and spread of high impact, evidence-based innovations across England’s NHS, benefiting patients, populations and NHS staff.
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Content ArticleThe neonatal practice development nurse and infant feeding midwife at Bedford Hospital NHS Trust led a programme of work to adopt and implement the ‘RAPP’ (Respirations, Activity, Perfusion, Position/Tone) tool in their maternity unit. This programme led to improved outcomes for new-born babies in the unit.
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Content ArticleThe findings of an independent investigation established to review the management, delivery and outcomes of care provided by the maternity and neonatal services of the University Hospitals of Morecambe Bay NHS Foundation Trust between January 2004 and June 2013.
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Content ArticleThe risks of accidentally dropping a baby are well known, particularly when a parent falls asleep while holding a baby; or when a parent or healthcare worker holding the baby slips, trips or falls. However, despite healthcare staff routinely using a range of approaches to make handling of babies as safe as possible, and advising new parents on how to safely feed, carry and change their babies, on rare occasions babies are accidentally dropped. This safety alert was issued after a consultant neonatologist raised concerns about an increase in the number of accidentally dropped babies in his organisation. A search of the National Reporting and Learning System (NRLS) for a recent 12 month period identified; 182 babies who had been accidentally dropped in obstetric/ midwifery inpatient settings (eight with significant reported injuries, including fractured skulls and/or intracranial bleeds), 66 babies accidentally dropped on paediatric wards, and two in mother and baby units in mental health trusts. Almost all of these 250 incidents occurred when the baby was in the care of parents or visiting family members.
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Content Article
Each Baby Counts (RCOG, 2019)
Patient Safety Learning posted an article in Maternity
Each Baby Counts is the Royal College of Obstetricians and Gynaecologists (ROCG's) national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. -
Content ArticleThis document is the second version of the Saving Babies’ Lives Care Bundle, which has been produced by NHS England to help reduce perinatal mortality across England. The second version of the care bundle brings together five elements of care that are widely recognised as evidence-based and/or best practice: reducing smoking in pregnancy, risk assessment, prevention and surveillance of pregnancies at risk of fetal growth restriction; raising awareness of reduced fetal movement; effective fetal monitoring during labour; reducing preterm birth.
