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Found 550 results
  1. Content Article
    Trust boards’ regular oversight of the quality and safety of maternity and neonatal services has been the subject of successive inquiries and reviews. In this report, the Sands and Tommy’s Joint Policy Unit review publicly available board papers and minutes for seven NHS Trusts in England. They analyse whether the information presented to boards, the process for review, and actions taken enabled boards to deliver effective oversight over the safety and quality of maternity and neonatal services.
  2. News Article
    Maternity services at Hull Royal Infirmary have recently been described in a damning report by the health watchdog as chaotic, unsafe and not fit for purpose. Three mothers, who claim staff missed signs of life-threatening conditions that could have killed them or their babies, have spoken to the BBC about their harrowing experiences at the hospital. One woman, a BBC journalist who does not want to be named, said she knew her newborn son was seriously ill within minutes of giving birth at the infirmary in 2021. "As soon as they handed him to me, I noticed something was wrong. He was panting and his breathing wasn't right," she said. Over the course of an hour, she said her concerns were dismissed by the newly-qualified midwife who said his breathing was "completely normal". "She kept reassuring me over and over that's how babies breathe. I felt like I was drowning surrounded by lifeguards," she said. But after being examined by a more experienced midwife, the baby was rushed to intensive care and diagnosed with potentially fatal sepsis. "It was like time stood still. The midwife ripped him off me and she slammed an oxygen mask on his face, called the crash team and he was taken away to the neonatal intensive care unit. "The anger I felt was overwhelming because I'd been saying for nearly an hour he was seriously ill. I was right and he had sepsis." A few months after her son's birth, she read about an inquest into the death of a four-day-old baby who had sepsis and was born at Hull Royal Infirmary. A coroner found that midwives had failed to respond to his infection quickly enough. "My blood ran cold because it was exactly the same circumstances that happened to me and that baby died. I thought they clearly haven't learned anything," she said. Read full story Source: BBC News, 6 November 2023
  3. News Article
    Pregnant women across the Democratic Republic of the Congo are to be offered free healthcare in an effort to cut the country’s high rates of maternal and neonatal deaths. Women in 13 out of 26 regions in the country will, by the end of the year, be entitled to free services during pregnancy and for one month after childbirth. Babies will receive free healthcare for their first 28 days under the scheme, which the government plans to extend to the rest of DRC – although there is no timetable for that yet. However, health workers have raised concerns that hospitals and medical centres are ill-equipped to cope with any increased demand on services. Some told the Guardian there were not enough staff, facilities or equipment to successfully introduce the $113m (£93m) programme, which is supported by the World Bank. The rollout of the programme comes amid nationwide strikes by nurses, midwives, technicians and hospital administrative staff, who are calling for higher pay and better conditions. Congo has one of the highest number of maternal and neonatal deaths in the world. Latest figures record the maternal morality ratio at 547 deaths for every 100,000 live births, and its neonatal rate – the number of babies dying before 28 days of life – at 27 per 1,000 live births. The minister of public health, Roger Kamba Mulamba, said the programme would free women from a “prison sentence”. He said: “Mothers today get healthcare without fear when they are pregnant. Babies today do not die because they have no access to antibiotics. Mothers today do not die because they cannot afford to pay for a caesarean delivery.” Read full story Source: The Guardian, 6 November 2023
  4. Content Article
    Sussex Community NHS Foundation Trust share their patient safety newsletters with the hub.
  5. News Article
    Parents of babies who have died or been harmed as a result of poor care are demanding that ministers order a public inquiry into repeated failings in NHS maternity units. They want Steve Barclay, the health secretary, to set up a judge-led statutory inquiry to investigate recurring problems in maternity services, which cost the NHS in England £2.6bn a year in damages. Babies are still being damaged and dying, despite previous inquiries into maternity scandals at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts recommending changes. The NHS’s failure to improve maternity safety is so alarming that a public inquiry is needed to finally ensure that women and babies no longer come to harm, the families say. The Maternity Safety Alliance, a group of relatives of newborns who have died due to lapses in NHS childbirth, warned that scandals will continue unless such an inquiry is held. “Our babies are too precious to keep on ignoring the reality that despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies. “Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed,” they said in a letter urging Barclay to intervene. Read full story Source: The Guardian, 31 October 2023
  6. News Article
    The parents of a baby boy who died at seven weeks old after a hospital did not give him a routine injection have described the failure as “beyond cruel”. William Moris-Patto was born in July 2020 at Addenbrooke’s hospital in Cambridge, where it was recorded in error that he had received a vitamin K injection – which is needed for blood clotting. The shot is routinely given to newborns to prevent a deficiency that can lead to bleeding. His parents, Naomi and Alexander Moris-Patto, 33-year-old scientists from Chatteris, Cambridgeshire, want to raise awareness about the importance of the vitamin after a coroner concluded William would not have died had the hospital administered the injection. On Friday, the coroner Lorna Skinner KC described the omission as “a gross failure in medical care amounting to neglect”. Alexander Moris-Patto, a researcher at the University of Cambridge who recently co-founded William Oak Diagnostics to test for deficiencies in babies, said: “What’s come out of the inquest for me is that the systems they [the trust] put in place to try to prevent this happening again are not satisfactory.” He stressed the importance of the vitamin K injection, adding that about 1% of the UK population opt out of it. “We want people to know more about it, to understand how critical it can be, and for hospitals to take seriously the responsibility they have in those first precious hours of a baby’s life,” he said. Read full story Source: The Guardian, 29 October 2023
  7. News Article
    To new parents processing the shock of delivery and swimming in hormones, newborns can feel like a tiny, terrifying mystery; unexploded ordinance in a crib. “We were totally unprepared,” says Odilia. Neither she or her husband had ever changed a nappy and had no idea the baby needed feeding every three hours. “If you’re a new mum or dad, you have no idea,” recalls Anouk, a new mother. “I’m a doctor,” says Zarah, another new mother, incredulously. “So, you would expect that I’d know something, and I knew some things, but you really don’t have any clue.” The difference for these new parents, compared to the rest of us, is that they gave birth in the Netherlands. That meant help was instantly at hand in the form of the kraamzorg, or maternity carer. Everyone who gives birth in the Netherlands, regardless of their circumstances, has the legal right – covered by social insurance – to support from a maternity carer for the following week. These trained professionals come into your home daily, usually for eight days, providing advice, reassurance and practical help. It’s a different role to midwives, who continue to monitor women and babies after the birth in the Netherlands; the maternity carer updates the midwife on the mother and baby’s health and progress as well as supporting the parents as they come to terms with their new child. A maternity carer in the Netherlands, explains Betty de Vries of Kenniscentrum Kraamzorg, the organisation that registers maternity carers, “takes care of the woman the first week, advises her on breastfeeding and bottle feeding, hygiene, gives advice … everything to do with safe motherhood and a safe baby. She is there for the whole day most of the time so she can see how they are doing.” Her colleague, director Esther van der Zwan, adds: “It’s a lot of responsibility.” To prepare, maternity carers train for three years – a combination of academic and on-the-job placements – and have regular refresher training in everything from CPR to breastfeeding support.
  8. News Article
    Valproate-containing medicines will be dispensed in the manufacturer’s original full pack, following changes in regulations coming into effect on Wednesday 11 October 2023. The Medicines and Healthcare products Regulatory Agency (MHRA) has published new guidance for dispensers to support this change. Following a government consultation, this change to legislation has been made to ensure that patients always receive specific safety warnings and pictograms, including a patient card and the Patient Information Leaflet, which are contained in the manufacturer’s original full pack. These materials form a key part of the safety messaging and alert patients to the risks to the unborn baby if valproate-containing medicines are used in pregnancy. The changes follow a consultation on original pack dispensing and supply of medicines containing sodium valproate led by the Department of Health and Social Care (DHSC), in which there was overwhelming support for the introduction of the new measures, to further support safety of valproate-containing medicines. Minister for Public Health, Maria Caulfield, said: “This safety information will help patients stay informed about risks of valproate, and I encourage all dispensers of valproate to consult the new guidance carefully. “This continues our commitment to listening and learning from the experiences of people impacted by valproate and their families and using what we hear to improve patient safety.” Read full story Source: MHRA, 11 October 2023
  9. News Article
    An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies. Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance. In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019. Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said. The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month. However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly. Read full story (paywalled) Source: The Times, 10 October 2023
  10. News Article
    Almost two-thirds of maternity units provide dangerously substandard care that puts women and babies at risk, the NHS watchdog has said in a damning report. The Care Quality Commission (CQC) has rated 65% of maternity services in England as either “inadequate” or “requires improvement” for the safety of care – up from 54% last year. Services are beset by a host of problems, including serious staff shortages and internal tensions, which mean that too many mothers and their babies receive care that is not good enough, it said. Women too often face delays in accessing care, do not receive the one-to-one care from a midwife to which they are entitled or experience communication problems with staff looking after them, including being shouted at by midwives. The CQC judged overall quality of care to be inadequate or require improvement at 85 maternity units, almost as many at which it rated it to be either good or outstanding – 87. The number of units offering substandard care has soared by 30 in the last year, from 55 to 85. It said that, having inspected 73% of all maternity units, “the overarching picture is one of a service and staff under huge pressure. People have described staff going above and beyond for women and other people using maternity services and their families in the face of this pressure. “However, many are still not receiving the safe, high-quality care that they deserve.” Read full story Source: The Guardian, 20 October 2023
  11. News Article
    Health advocates in the USA are calling on the Biden administration to declare a public health emergency over a steep rise in congenital syphilis cases. The easily treated infection has quintupled in 10 years and can have harrowing impacts on children. Congenital syphilis happens when a baby contracts syphilis from its mother. Up to 40% of babies born to untreated mothers will be stillborn or die. Others can be left with severe birth defects such as bone damage, anaemia, blindness or deafness, and “neurological devastation”. “There is not a single baby that should be born in the US with syphilis,” David Harvey, the executive director of the National Coalition of STD Directors, told the Guardian. “We will be judged very severely as a country and a society for allowing this to happen to babies, when it is so easy to diagnose, treat and prevent this disease.” Rates of the disease have reached a nearly 30-year high just as supplies of the preferred medication, called Bicillin L-A, are in short supply. Syphilis can be cured with between one and three shots of the medication. Pfizer is the only manufacturer of the medication, a form of the first antibiotic ever synthesized, penicillin. The company said it does not expect shortages to be resolved before 2024, and blamed low supply partly on the increase in syphilis cases. Read full story Source: The Guardian, 17 October 2023
  12. News Article
    A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023
  13. News Article
    The Centers for Disease Control and Prevention alerted doctors nationwide Monday about a limited availability of certain doses of a newly approved antibody drug given to infants to prevent RSV infection. Cases of RSV, or respiratory syncytial virus, have started to rise as cold and flu season begins. "RSV season is here," said Dr. Buddy Creech, a pediatric infectious disease doctor at Vanderbilt University Medical Center in Nashville, Tennessee. "We are seeing a substantial increase in the amount of RSV such that in many areas, it has become the most commonly identified respiratory virus causing disease in children. "This is one of the reasons why there's probably a lot of scrambling going on," he said, "to identify those babies at highest risk and to try to prioritize them, since it's such a limited resource right now." Read full story Source: NBC News, 23 October 2023
  14. Content Article
    This is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
  15. Content Article
    Research clearly demonstrates that from conception onwards, rapid brain development influences the cognitive, emotional and social development of babies and young children. Pre-conception to five years is an important time in a child’s life and critical for brain and psychological development, the formation of enduring relationship patterns, and emotional, social and cognitive functioning – all of which are foundations for healthy development, but which can also confer protection against mental health conditions. The establishment of sensitive, attuned and responsive relationships is essential for positive mental health and wellbeing and underpins interventions to address problems in social and emotional development, poor mental health and mental health conditions in under 5s. This report by the Royal College of Psychiatrists (RCPsych) aims to outline the importance of mental health in babies and young children under 5 to policy makers, commissioner and healthcare practitioners.
  16. Content Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) are providing an update on a retrospective observational study on the risk to children born to men who took valproate in the 3 months before conception and on the need for the re-analysis of the data from this study before conclusions can be drawn. No action is needed from patients.  For female patients, healthcare professionals should continue to follow the existing strict precautions related to preventing the use of valproate in pregnancy (Valproate Pregnancy Prevention Programme).
  17. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
  18. Content Article
    This is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023. 
  19. Content Article
    In this article, Sharon Hartles highlights the high-profile legal battle involving numerous Primodos-affected claimants against pharmaceutical companies and the government. The court ruled against the claimants, dismissing their claims related to hormone pregnancy tests and foetal harm. This decision led to disappointment and criticism from advocates, MPs, and academics involved in the Primodos scandal. Sharon Hartles is affiliated with the Risky Hormones research project, which is an international collaboration in partnership with patient groups. Additionally, she is a member of the Harm and Evidence Research Collaborative at the Open University. Related reading on the hub: Primodos 2023: The fight for justice continues for the Association for Children Damaged by Hormone Pregnancy Tests Primodos, mesh and sodium valproate: Recommendations and the UK Government’s response Primodos: The next steps towards justice Patient Safety Spotlight interview with Marie Lyon, chair of the Association for Children Damaged by Hormone Pregnancy Tests
  20. Content Article
    Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period.
  21. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
  22. Content Article
    On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.
  23. News Article
    A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely. Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported. Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”. The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said. She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home. Brody said the whole experience “felt so grotesque”. “When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme. The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E. Read full story Source: The Guardian, 30 May 2022
  24. News Article
    Donna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families. The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose. It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust. In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.” “After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.” “We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.” Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care." “I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.” Read full story Source: BBC News, 26 May 2022
  25. News Article
    The former health secretary Jeremy Hunt has claimed the government snubbed bereaved families’ requests for Donna Ockenden to chair a review into maternity services in Nottingham as she is “too independent”. Hundreds of families involved in the Nottingham maternity scandal review have called for Ms Ockenden, chair of the Shrewsbury maternity scandal inquiry, to take over the investigation. NHS England had attempted to appoint a former healthcare leader, Julie Dent to chair the review. However, following pressure from families not to accept, Ms Dent announced shortly after she would be declining the role. Following the families’ calls for Ms Ockenden, Mr Hunt, chair of the government’s health committee, said on Wednesday: “I can’t see any other barriers to appointing her but sounds like she still won’t be. For some reason the Department of Health appears to think she is too independent – which is of course precisely why Nottingham families do have confidence in her. It feels like another own goal.” Families involved in the Nottingham maternity review, which will now cover almost 600 cases, have said they’ve been left in limbo by NHS England after if informed them of an interim report which has been completed by the review team. This follows several letters from families to health secretary Sajid Javid raising concerns over the review and calls for it to be overhauled. Speaking with The Independent, a couple whose son died under the care of Nottingham University Hospitals Foundation Trist said: “The key to successful long term change is developing a relationship with harmed families, built on trust, sensitivity and understanding. The current review does not command this. The relationship is untenable.” Read full story Source: The Independent, 26 May 2022
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