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Found 541 results
  1. News Article
    Exploitative and “underhand” marketing of formula milk is preventing millions of women from breastfeeding, according to a series of reports published in the Lancet. The reports, by 25 experts from 12 countries, including paediatricians, public health specialists, scientists, economists and midwives, finds that the commercial milk formula companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women and children”. Breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases and death, while also reducing risks of obesity and chronic diseases in later life. It also helps protect mothers against breast and ovarian cancers. The World Health Organization (WHO) recommends exclusively breastfeeding babies for the first six months and giving breast milk alongside solid food until the age of two or beyond. Over three reports, the series reveals how, more than 40 years since the World Health Assembly developed a voluntary international code prohibiting the marketing of infant formula, widespread violation of the code persists, with promotion of infant formula milk continuing in about 100 countries in every region of the world since the code was adopted. Read full story Source: The Guardian, 7 February 2023
  2. Content Article
    This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies.
  3. News Article
    East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023
  4. News Article
    Nurse Lucy Letby sent a sympathy card to the grieving parents of a baby girl just weeks after she allegedly murdered the infant, a court has heard. She is accused of trying to kill the premature baby, referred to as Child I, three times before succeeding on a fourth attempt on 23 October 2015. She denies murdering seven babies and attempting to murder 10 others. Manchester Crown Court was shown an image of a condolence card Ms Letby sent to the family of Child I ahead of her funeral on 10 November. The card was titled "your loved one will be remembered with many smiles". Inside, Ms Letby wrote: "There are no words to make this time any easier. "It was a real privilege to care for [Child I] and get to know you as a family - a family who always put [Child I] first and did everything possible for her. "She will always be part of your lives and we will never forget her. "Thinking of you today and always. Lots of love Lucy x." It is alleged that before murdering Child I, Ms Letby attempted to kill the infant on 30 September and during night shifts on 12 and 13 October. The prosecution said she harmed the premature infant by injecting air into her feeding tube and bloodstream before she eventually died in the early hours of 23 October 2015. Read full story Source: BBC News, 2 February 2023
  5. News Article
    Hepatitis B transmission from mothers to babies has been eliminated in England, according to the World Health Organisation (WHO). The WHO elimination target is that less than 2% of babies born to mothers with hepatitis B go on to develop the infection. And data from the UK Health Security Agency (UKHSA) shows the figure for England currently stands at 0.1% The UKHSA said progress had been made in tackling the viral infection, which can cause liver damage, cancer and death if left untreated. A six-in-one vaccine is offered to all babies on the NHS when they are eight, 12 and 16 weeks of age. Health and Social Care Secretary Steve Barclay said: “We are paving the way for the elimination of hepatitis B and C, with England set to be one of the first countries in the world to wipe out these viruses.” Read full story Source: The Independent, 2 February 2023 .
  6. News Article
    Donna Ockenden, who is leading an independent review examining how dozens of babies died or were injured at the Nottingham University Hospitals (NUH) trust, is due to meet with chief executive of NUH, Anthony May, and other members of the NUH executive team. Speaking ahead of the meeting, she said: "The commitment I want to give to the women and families of Nottingham is that real learning, real improvement in maternity safety will happen throughout the life of this review. "It won't be a case of waiting until the end and then presenting the trust with a huge amount of learning that they then have to start putting in place. "Today's meeting with the trust is at executive level. Along with colleagues from NHS England, I'll be meeting with the chief executive and some of his colleagues to talk about how we will ensure that learning reaches the trust on a regular basis and in a timely way so families can be assured that the maternity improvement plan is including learning from our review." Read full story Source: BBC News, 2 February 2023
  7. News Article
    An acute trust has been fined a record sum by the Care Quality Commission for failing to provide safe maternity care, which resulted in the death of a baby after 23 minutes. Nottingham University Hospitals must pay a fine of £800,000 within two years. It is only the second time the regulator has brought a case against a NHS maternity service, and the highest fine ever given for failings of this nature. The trust pleaded guilty earlier this week to two charges of failing to provide safe care and treatment to Sarah Andrews and her baby daughter Wynter Andrews at Queen’s Medical Centre in 2019, a short time after her birth by Caesarean section. This guilty plea saw the fine reduced from £1.2m. An inquest in 2020 found the death was a “clear and obvious case of neglect”. It was also found there was “an unsafe culture prevailing within maternity services”, including a “failure to listen and respond to staff safety concerns”. Read full story (paywalled) Source: HSJ, 27 January 2023
  8. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home.
  9. News Article
    A hospital trust is facing a fine in a criminal prosecution over the death of a baby. The Care Quality Commission (CQC) is prosecuting Nottingham University Hospitals (NUH) NHS Trust over the death of Wynter Andrews. Wynter died 23 minutes after she was born by Caesarean section in September 2019 at the Queen's Medical Centre.  The prosecution is one of only two the CQC has brought against an NHS maternity unit. The trust is due to face sentencing at Nottingham Magistrates' Court later. Read full story Source: BBC News, 25 January 2023
  10. Content Article
    This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
  11. Content Article
    This Health and Social Care Select Committee report reviews the progress that the UK Government has made in implementing the recommendations of the Independent Medicines and Medical Devices Safety Review, sometimes referred to as the Cumberlege Review. You can read Patient Safety Learning’s reflections on this report here.
  12. Content Article
    Institute of Health Visiting executive director Alison Morton warns national policy has developed a “baby blind spot” amid the NHS crisis, with many young children missing out on government’s promise of the “best start in life”, and calls for a shift towards prevention and early intervention.
  13. News Article
    With the distressing spate of news reports about mums and ­babies who weren’t kept safe in hospital, an initiative in the Midlands to improve patient safety in maternal and acute care settings comes as a relief. The newly announced Midlands Patient Safety Research Collaboration will bring together NHS trusts, ­universities and private business to evaluate how digital tools can help clinical decision making and reduce danger for patients. Problems can arise if communication is poor between medics when patients move between departments. Professor Alice Turner of Birmingham University said: “The power of new technology available to us means that we can address one of the ongoing areas of risk for patients, which is effective communication and clinical decision making. “The new collaboration will be looking at how digital tools can make a real difference to reduce risks and support patient safety in the areas of acute medicine and maternal health.” Digital decision-making tools could improve prescribing and personalised management for patients needing emergency care. Importantly, these tools should provide a smoother flow of information between healthcare professionals in acute care between hospitals, doctors and the West Midlands Ambulance Service, and hopefully reduce risks of patient harm at key points during acute care. Read full story Source: The Mirror, 18 December 2022
  14. Content Article
    On the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost
  15. News Article
    Rare genetic disorders will be diagnosed and treated in babies thanks to a project to sequence the complete DNA of 100,000 newborns. It should spare hundreds of families in England months, or years, of anguish waiting to find out why their children are ill. The project is the first time that whole genome sequencing (WGS) has been offered to healthy babies in the NHS. It will screen for around 200 disorders, all of them treatable. The Newborn Genomes Programme, to begin next year, is thought to be the biggest study of its kind in the world. If successful, it could be rolled out across the country. Owen, 9, has an extremely rare genetic condition which affects his growth and development. Called THRA-related congenital hypothyroidism, it is one of the disorders which will be included in the new genetic test. Father, Rob Everitt, told the BBC: "I think of all the hours we spent in hospital waiting rooms, getting referred around different departments, all the tests - some of which were quite invasive - that drew a blank every time. I lost count of how many doctors and consultants we went to see and how many tests they did on him." Mother, Sarah Everitt, says getting the diagnosis was life-changing: "It was like winning the lottery….because we knew there was a treatment pathway; we knew we could get him support and he could attend a mainstream school." Read full story Source: BBC News, 13 December 2022
  16. News Article
    Lucy Letby used a plunger to force milk and air into one of the babies she is accused of attempting to murder, a medical expert has told a court. The alleged attack caused the infant’s stomach to distend to such a degree that she then projectile vomited a “massive” amount of milk so violently that the material left her cot and splashed over a chair several feet away. Staff at the Countess of Chester Hospital managed to save Baby G’s life but the incident was so catastrophic that it caused the child severe brain damage. Seven years later she still suffers from quadriplegic cerebral palsy. Dr Dewi Evans, a consultant paediatrician called in by the prosecution, said the use of a plunger on the end of a syringe was the only explanation for the baby’s sudden collapse in the early hours of 7 September 7 2015. Letby, 32, of Hereford, is accused of murdering seven children in the neonatal unit of the hospital in Cheshire, and of ten attempted murders, between June 2015 and June 2016. She denies all the charges. Read full story (paywalled) Source: The Times, 13 December 2022
  17. Content Article
    This report from the National Child Mortality Database (NCMD) covers the two-year period from 2019 to 2021, and is unique in two ways. It is the first national report to have investigated all unexpected deaths of infants and children—not just those that remained unexplained. It is also the first national review of the 'multi-agency investigation process' into unexpected deaths. The report found that, of all infant and child deaths occurring between April 2019 and March 2021 in England, 30% occurred suddenly and unexpectedly, and of these 64% had no immediately apparent cause. Other key findings relating to sudden and unexpected infant deaths (under 1 year) include: 70% were aged between 28 and 364 days, and 57% were male Infant death rates were higher in urban areas and the most deprived neighbourhoods For sudden and unexpected infant deaths that occurred during 2020 and had been fully reviewed, 52% were classified as unexplained (Sudden Infant Death Syndrome) and 48% went on to be explained by other causes such as metabolic or cardiac conditions.
  18. News Article
    More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare. Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services. The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality. Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient. Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life. They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety. NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics. A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern". Read full story (paywalled) Source: The Herald, 10 December 2022
  19. News Article
    Vulnerable parents may be forced to resort to unsafe practices to feed their babies because of sharp increase in the cost of infant formula, charities have warned. The price of the cheapest brand of baby formula has leapt by 22%, according to analysis by the British Pregnancy Advisory Service (BPAS). BPAS said the cost of infant formula needed to safely feed a baby in the first six months of their life was no longer covered by Healthy Start vouchers, which are worth £8.50 a week and provided to women in England, Wales and Northern Ireland who are pregnant or have young children. The charity Feed said families that were unable to afford enough infant formula had resorted to watering down the product or feeding their babies unsuitable food such as porridge. BPAS’s chief executive, Clare Murphy, said: “We know that families experiencing food poverty resort to unsafe feeding methods, such as stretching out time between feeds and watering down formula. The government cannot stand by as babies are placed at risk of malnutrition and serious illness due to the cost of living crisis and the soaring price of infant formula. “The government must increase the value of Healthy Start vouchers to protect the health of the youngest and most vulnerable members of our society.” Read full story Source: The Guardian, 6 December 2022
  20. News Article
    More than 1,000 referrals to admit very sick or premature babies to neonatal units were rejected in the last year due to a lack of beds, data obtained by HSJ has revealed. Nineteen trusts turned down a total of 2,721 requests to admit a baby to their level three neonatal intensive care unit – those for the most serious cases – specifically due to a lack of a bed, between 2019-20 and 2021-22, with 1,345 such refusals taking place in 2021-22. Experts told HSJ the issue – which appears to have led to families having to travel very long distances from their homes – was due to a shortage of staff, especially nurses, meaning insufficient beds (normally referral to as cots in neonatal care) can be opened. A British Association of Perinatal Medicine spokesperson told HSJ: “Neonatal intensive care units should run at less than 80% occupancy on average to allow for peaks and troughs in activity. There are a significant number which are having to run over that capacity limit which can cause flow problems – we’re a bit like an A&E that can’t stack the ambulances outside – once the baby is there, it has to come and we’re not able to control those admissions.” Read full story (paywalled) Source: HSJ, 1 December 2022
  21. News Article
    The NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, after 700 families previously came forward with their concerns. Of these, the number of families expected to be covered by the probe is more than 1,500 – surpassing the 1,486 examined during the UK’s current largest maternity scandal in Shrewsbury. Read full story Source: The Independent, 30 November 2022
  22. News Article
    Bosses at Nottingham's crisis-hit maternity units are set to miss a deadline for clearing a backlog of incomplete "serious incident" investigations. Nottingham University Hospitals Trust (NUH) has 53 outstanding maternity incidents yet to be investigated. The trust had said it aimed to complete investigations by December 23. But director of midwifery Sharon Wallis says they have not progressed as quickly as she had hoped. The Local Democracy Reporting Service said the trust has managed to clear a number of those incidents - but it declared another nine in September and October. An independent review team, led by senior midwife Donna Ockenden, is examining dozens of baby deaths at the trust. Read full story Source: BBC News, 25 November 2022
  23. News Article
    A maternity unit criticised for the preventable stillbirth of a baby is under investigation after the unexpected death of a second baby. The newborn baby died in December last year after her birth at the standalone midwifery-led unit (MLU) at Lagan Valley Hospital in Lisburn. Despite this, the unit continued to operate as normal for another three months when the South Eastern Trust temporarily paused births at the MLU. The second tragedy came four years after Jaxon McVey was stillborn when his delivery at the unit went catastrophically wrong. A post-mortem found he died as a result of shoulder dystocia – an obstetric emergency where the head is born but the shoulder becomes trapped behind the pubic bone. Jaxon’s mum, Christine McCleery, has hit out at the South Eastern Trust and raised concerns over the measures put in place following his stillbirth on Mother’s Day 2017. “I feel like they didn’t learn from Jaxon,” she said. “I don’t know if any other babies died before Jaxon, but I know one died afterwards. Read full story (paywalled) Source: The Independent, 23 November 2022
  24. News Article
    Nearly a fifth of trusts providing maternity care have been red rated for their infant mortality rates in a national audit. Twenty-three trusts were flagged for their perinatal mortality in the latest Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries audit for maternity services. Trusts with mortality rates more than 5% higher than an average of peer group providers are given a red rating. The report was published last month and looked at data for 2020. Average perinatal mortality rates have been falling across England since 2013, although there is significant variation across England. Six trusts in the latest audit were red rated for both stillbirths and neonatal mortality; Buckinghamshire Healthcare; Gloucestershire Hospitals; University Hospitals Dorset; Sandwell and West Birmingham Hospitals; University Hospitals Coventry and Warwickshire; and University Hospitals of Leicester. Twenty-three trusts rated red on a combined perinatal mortality indicator (including the six listed above). For 17 of them, their mortality rates were not high enough on one of the stillbirth or neonatal measures to be red rated, but sufficiently high enough on both indicators to tip their overall extended overall perinatal rating into the red. Andrew Furlong, medical director of University Hospitals Leicester, said: “Where learnings have been identified from reviews of care, we have developed robust action plans and strengthened care practice to shape and improve future services.” These include aiming to improve access to interpreters, provide clearer medical review guidelines, and update ultrasound scanning processes, he added. Read full story (paywalled) Source: HSJ, 21 November 2022
  25. 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.
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