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The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to help improve patient safety in relation to the instructions 999 call handlers give to women and pregnant people who are waiting for an ambulance because of an emergency during their pregnancy. The HSIB investigation reviewed the case of Amy, who was 39 weeks and 4 days pregnant with her first child. She contacted 999 after experiencing abdominal cramps and bleeding. While waiting for an ambulance to arrive, Amy received pre-arrival instructions which were generated through a clinical decision support system (CDSS) from a non-clinical call handler. Amy was then taken by ambulance to hospital where her baby, Benjamin, was delivered by emergency caesarean section. Amy had excessive blood loss due to a placental abruption and was admitted to the high dependency unit for 12 hours following the birth. Benjamin required resuscitation to help him breathe on his own, he was intubated, and he received 72 hours of therapeutic cooling. He spent 13 days in hospital.

In March 2020, the Healthcare Safety Investigation Branch (HSIB) published a national learning report to highlight the themes emerging from the initial investigations carried out as part of their maternity investigation programme. These initial investigations were carried out between April 2018 and December 2019. One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia). This was identified as an area where further analysis could benefit system-wide learning.

The British Association of Perinatal Medicine is inviting parents of babies who have spent time in a neonatal intensive care unit (NICU) to submit questions for neonatal research to the Neonatal Priority Setting Partnership. The partnership is made up of healthcare professionals and parent representatives that have come together to oversee a process to identify and prioritise research questions that can be tested in randomised trials in UK neonatal care. Answers to the questions submitted should improve neonatal care and reduce unwanted variations in practice. Questions can be submitted until 28 February 2022.

This blog describes the experience of Colonel Steven Coffee, Cofounder of Patients for Patient Safety US, who experienced a series of medical errors following the birth of his son. After a missed diagnosis of galactosemia, his son suffered liver failure and underwent a liver transplant at eight weeks old. Following his operation, the hospital where he was being treated did not have access to the powdered soy milk which was essential for his son's recovery. This experience spurred Colonel Coffee on to become an advocate for patient quality and safety in health care. For the last nine years, he has worked toward improved patient safety as the first community chair of MedStar Health’s Patient and Family Advisory Council for Quality and Safety (PFACQ).