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Found 549 results
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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.
  9. News Article
    A new treatment to protect babies against a common and potentially dangerous winter virus has been approved by the Medicines and Healthcare products Regulatory Agency (MHRA). Respiratory syncytial virus (RSV) is the main reason children under five end up in hospital. In a normal winter, RSV mostly causes coughs and colds which clear up in a couple of weeks - but it can be particularly serious in infants under the age of two, causing severe lung problems such as bronchiolitis and pneumonia. Every year, about 29,000 babies need hospital care for RSV and most have no other health issues beforehand. The new antibody treatment, called nirsevimab, from Sanofi and AstraZeneca, has already been shown to reduce lower respiratory tract infections caused by RSV by 74.5% in trials involving 4,000 babies. It works by preventing RSV from fusing to cells in the respiratory tract and causing infections. But it still needs more research in larger numbers of babies before it can be used on the NHS. Researchers now plan to investigate whether it can cut the number of babies needing hospital care for RSV, and are urging parents to sign up to their study. The study is open to newborn babies and those up to 12 months old. Only one visit for the antibody injection is needed, and follow-up sessions happen via an app. Co-study leader Dr Simon Drysdale, consultant paediatrician in infectious diseases at London's St George's Hospital, said the treatment could eventually be given at birth to offer protection for the first months of life, or during routine immunisations at two months old. Read full story Source: 10 November 2022
  10. News Article
    The death of a three-day-old baby could have been avoided if medical professionals had acted differently, a coroner concluded. Rosanna Matthews died three days after being delivered at Tunbridge Wells Hospital in Kent in November 2020. The hospital trust apologised, saying the level of care for Ms Sala and her daughter “fell short of standards”. Ms Sala told the inquest midwives were "bickering" and appeared confused during her labour. She claimed that if she had been allowed to start pushing when she wanted to, instead of waiting as midwives advised, Rosanna would have lived. Rachel Thomas, then deputy head of gynaecology and midwifery, said there had been "errors in communication". Following the conclusion of the inquest, the coroner ruled Rosanna died following a “prolonged period of avoidable hypoxia”, which led to brain damage. The coroner, sitting in Maidstone, also found midwives at the hospital failed to recognise that Rosanna was already unwell with congenital pneumonia. Ms Sala said her daughter could have lived had medical professionals acted differently on the day of her birth. Read full story Source: BBC News, 8 November 2022
  11. News Article
    The proportion of newborn babies receiving a timely health visitor check-in has fallen sharply, with one in five missing out in the most recent statistics available. Official data reveals that only 82.6% of babies received a new birth visit within their first fortnight in 2021-22, as is recommended, and in the fourth quarter of the year it dropped as low as 79.3%. This is the lowest proportion recorded in recent years in the annual dataset on health visitor service delivery metrics, published by the Office for Health Improvements and Disparities. According to the NHS website, a health visitor new birth visit is supposed to take place between 10 and 14 days after birth and is designed to offer advice on issues including safe sleeping, vaccinations, infant feeding, infant development, and adjusting to life as a parent. Kate Holmes, head of support and information at charity The Lullaby Trust, said: “Safer sleep saves babies’ lives and all families should be given advice on how to reduce the risk of sudden infant death syndrome for their baby. The new birth visit is a key opportunity for health visitors to talk to families about safer sleep and to provide them with information and support that takes their individual and family circumstances into account.” Read full story (paywalled) Source: HSJ, 7 November 2022
  12. Content Article
    On 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
  13. News Article
    A baby was left "severely disabled" after a delay during his delivery by Caesarean section, a High Court judge has been told. Betsi Cadwaladr health board will pay £4m in compensation after a negligence claim was brought by one of the boy's relatives. He has required 24-hour care since his birth in 2018 at Glan Clwyd Hospital in Denbighshire. The hospital apologised, saying doctors are "working hard" to learn lessons. "We are extremely sorry," barrister Alexander Hutton KC, representing the health board, told Mr Justice Soole. "[Betsi Cadwaladr] is working hard to learn lessons from this case," he added. Read full story Source: BBC News, 2 November 2022
  14. Content Article
    Maternity costs make up the largest cost to the NHS in value of claims. The Early Notification Scheme provides a faster and more caring response to families whose babies may have suffered severe harm. 'The second report: The evolution of the Early Notification Scheme' provides an overview of progress made since the report into the first year of the scheme, which was published in 2019. The report updates on the progress of the key recommendations which were made in the first report and reflects on modifications and improvements made to the scheme since its launch five years ago. It provides an analysis of the main clinical themes, based on a small cohort of cases, and makes recommendations to further improve outcomes for affected families.
  15. Content Article
    The HypoBaby blog is written by the parents of Noah, a young boy who was diagnosed with type 1 diabetes as a baby. In this post, they describe Noah's diagnosis and why it took so long to work out that it was diabetes causing his symptoms. Noah ended up in diabetic ketoacidosis (DKA) and needed emergency treatment. They highlight the importance of being aware of the symptoms of type 1 diabetes, stating that if they had been aware of the symptoms, he may have been diagnosed sooner.
  16. Content Article
    This guideline describes good patient experience for babies, children and young people, and makes recommendations on how it can be delivered. It aims to make sure that all babies, children and young people using NHS services have the best possible experience of care. It includes recommendations on: overarching principles of care communication and information planning healthcare consent, privacy and confidentiality advocacy and support improving healthcare experience, including healthcare environments accessibility, continuity and coordination
  17. Content Article
    Sodium valproate is a medication used to treat epilepsy, bipolar disorder and migraines, but it can cause birth defects, learning disabilities and developmental problems in babies if taken during pregmamcy. This video by Central and North West London NHS Foundation Trust discusses the various effects of using valproate, including the potential harmful effects the medication can have on unborn foetuses. It features a conversation between a pharmacist and patient discussing the need for a valproate pregnancy prevention programme if the patient is to be prescribed valproate.
  18. Content Article
    In this BMJ feature, journalist Emma Wilkinson looks at how a shortage of health visitors in England is leaving babies and children exposed to safeguarding risks, late diagnosis and other problems. An estimated third of the health visitor workforce has been lost since 2015, and research by the Parent-Infant Foundation suggests that 5000 new health visitors are needed. Families are not getting the minimum recommended number of contacts with health visitors during the first three years of life, and research into the impact of this on children's outcomes is ongoing. Emma speaks to different mothers, including Phillippa Guillou, who had a baby in 2020 and struggled to breastfeed. Philippa felt unsupported and ignored by her local health visiting service, who only saw her once by videocall when her baby was one year old.
  19. Content Article
    This debate begins with a statement by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, regarding the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust. It is followed by questions from MPs in the chamber and the Minister's responses.
  20. Content Article
    Reports showing that babies and mothers died or were harmed as a result of failures by, and sometimes heartless cruel treatment in, NHS maternity units are becoming worryingly common. Dr Bill Kirkup’s just-published 192-page exposé of an appalling catalogue of failings at East Kent NHS trust between 2009 and 2020 is the second in the last 12 months. As many as 45 babies and 23 mothers in East Kent died avoidably during that time because their care was substandard, his inquiry found. March brought Donna Ockenden’s grim findings about poor maternity care at the Shrewsbury and Telford trust. And Kirkup produced the first detailed exposition of what inadequate care of women and their offspring during childbirth looked like when in 2015 he laid bare “serious and shocking” lapses in care at Morecambe Bay trust. A fourth official inquiry, again being led by Ockenden, is under way into death, brain damage and other horrendous outcomes at the Nottingham trust. Families affected claim that, despite coroners’ findings, close scrutiny of the trust by regulators, media coverage of lapses in care and pressure for change, “babies, mothers and their families continue to be harmed”. No wonder Rob Behrens, the NHS Ombudsman, says: “The phrase ‘never again’ is starting to ring hollow.”
  21. Content Article
    This is a written statement to the House of Commons by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, on behalf of the UK Government. It regards the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust.
  22. Content Article
    In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.
  23. News Article
    A key national policy change recommended by the inquest which led to the East Kent maternity inquiry will not be implemented until next February – more than three years after it was called for by a coroner. The recommendation – that obstetric locum doctors be required to demonstrate more experience before working – was made in a prevention of future deaths report following the inquest into the death of seven-day-old Harry Richford at East Kent Hospitals University Foundation Trust. The remaining 18 recommendations from the PFD report were requiring specific actions by the trust, rather than national policy makers. The trust says they have been implemented. However, NHS England and the Royal College of Obstetricians and Gynaecologists have only in recent months produced guidance on using short-term locums in these services, and it will not come into effect until February. When it does, it will require them to complete a certification of eligibility, demonstrating they have had recent experience in a number of clinical situations, including complex Caesarean sections. Middle-grade locums have until next February to gain the certificate. The independent inquiry into maternity at the trust – prompted by Harry’s death – will report tomorrrow, Wednesday 19 October, and is expected to be highly critical of the trust, and of national efforts to make services safe over recent years. Read full story (paywalled) Source: 18 October 2022
  24. News Article
    Imtiaz Fazil has been pregnant 24 times, but she only has two living children. She first fell pregnant in 1999 and, over the subsequent 23 years, has had 17 miscarriages and five babies die before their first birthdays due to a rare genetic condition. The 49-year-old, from Levenshulme in Manchester, told BBC North West Tonight her losses were not easy to talk about, but she was determined to do so, in part because such things remained a taboo subject among South Asian groups. She said she wanted to change that and break down the stigma surrounding baby loss. She said her own family "don't talk to me very much about the things" as they think "I might get hurt [by] bringing up memories". "It's too much sadness; that's why nobody approaches these sort of things," she said. Sarina Kaur Dosanjh and her husband Vik also have the hope of breaking the silence surrounding baby loss. The 29-year-olds, from Walsall in the West Midlands, have set up the Himmat Collective, a charity which offers a virtual space for South Asian women and men to share their experiences. The couple, who have had two miscarriages in the past two years, said the heartache was still not something that people easily speak about. "I think it's hidden," Sarina said. "It's really brushed under the carpet." Read full story Source: BBC News, 13 October 2022
  25. News Article
    The grandfather of a baby who died at a hospital that was fined over failings in the delivery has spoken of his five-year fight for justice. Derek Richford was speaking as an independent report into baby deaths at the East Kent Hospitals Trust will be released this week. He said he "came up against a brick wall" while searching for answers over the death of grandson Harry Richford. An inquest into Harry's death at Margate's Queen Elizabeth the Queen Mother Hospital in 2017 found it was wholly avoidable and contributed to by neglect. Coroner Christopher Sutton-Mattocks said the inquest, which was finally held in 2020, was only ordered due to the family's persistence. The following year the trust was fined £733,000 after admitting failing to provide safe care and treatment for mother Sarah Richford and her son following a prosecution by the Care Quality Commission (CQC). Mr Richford said: "To start with we felt fairly alone and we felt like we were coming up against a brick wall. "The trust were refusing at that time to call the coroner. They were reporting Harry's death as 'expected'. "We didn't contact anyone other than the CQC just to say 'look there's been a problem here'." He said at a meeting with the trust, more than five months later, "we suddenly realised that there were a huge [number] of errors". Mr Richford told the BBC: "It took me about a year to come up with all the detail I needed and to speak to all the right people." He said the family then spoke to the Health Safety Investigation Branch who found there were issues. Mr Richford also tracked down a "damming" report by the Royal College of Obstetricians and Gynaecologists (RCOG). "In the end it was like peeling back the layers of an onion, and the more you took off, the more you found," he said. Read full story Source: BBC News, 18 October 2022
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