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Found 554 results
  1. 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.
  2. 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.
  3. 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
  4. 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
  5. 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
  6. News Article
    The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened. In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services". An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings. It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented. The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015. Dawn Powell's newborn son Archie died in February 2019 aged four days. In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic. "For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said. Read full story Source: Sky News, 16 October 2022
  7. News Article
    NHS hospitals have claimed that babies born alive were stillborn, a Telegraph investigation has found, prompting accusations they were trying to avoid scrutiny. Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days. Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. The revelations raise questions over transparency at some NHS trusts. The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. Read full story (paywalled) Source: The Telegraph, 16 October 2022
  8. Content Article
    MBRRACE-UK is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to undertake the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). The aims of the MNI-CORP are to collect, analyse and report national surveillance data and conduct national confidential enquiries in order to stimulate and evaluate improvements in health care for mothers and babies. This report focuses on the surveillance of perinatal deaths from 22+0 weeks’ gestational age (including late fetal losses, stillbirths, and neonatal deaths) of babies born between 1 January and 31 December 2020.
  9. News Article
    Research suggests there are higher rates of stillbirth and neonatal death for those living in deprived areas and minority ethnic groups. A report from a team at the University of Leicester shows that while overall stillbirth and neonatal mortality rates have reduced, inequalities persist. MBRRACE-UK, the team that carried out the research, said it had looked at outcomes for specific ethnic groups. The report showed the stillbirth rate in the UK had reduced by 21% over the period 2013 to 2020 to 3.33 per 1,000 total births. Over the same period the neonatal mortality rate has reduced by 17% to 1.53 per 1,000 births. However despite these improvements, the authors found inequalities persisted, with those living in the most deprived areas, minority ethnic groups and twin pregnancies all experiencing higher rates of stillbirth. Elizabeth Draper, professor of perinatal and paediatric epidemiology at the university, said: "In this report we have carried out a deeper dive into the impact of deprivation and ethnicity on stillbirth and neonatal death rates. "For the first time, we report on outcomes for babies of Indian, Pakistani, Bangladeshi, Black Caribbean and Black African, rather than reporting on broader Asian and black ethnic groups, who have diverse backgrounds, culture and experiences. "This additional information will help in the targeting of intervention and support programmes to try to reduce stillbirth and neonatal death." Read full story Source: BBC News, 14 October 2022
  10. News Article
    There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’. A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry. In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history. Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review. However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death. Read full story (paywalled) Source: HSJ, 13 October 2022
  11. Content Article
    A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry.
  12. News Article
    Very sick babies and children will be diagnosed and start treatment more quickly thanks to a “revolutionary” new genetic testing service being launched by the NHS. Doctors will gain vital insights within as little as two days into what illnesses more than 1,000 newborns and infants a year in England have from the rapid analysis of blood tests. Until now, when doctors suspected a genetic disorder, such tests have sometimes taken weeks as they had to be done in a sequential order to rule out other possible diagnoses, delaying treatment. NHS England bosses say the service could save the lives of thousands of seriously ill children over time and will usher in “a new era of genomic medicine”. The clinical scientists, genetic technologists and bioinformaticians will carry out much faster processing of DNA samples, including saliva and other tissue samples as well as blood. They will share their findings with medical teams and patients’ families. “This global first is an incredible moment for the NHS and will be revolutionary in helping us to rapidly diagnose the illnesses of thousands of seriously ill children and babies, saving countless lives in the years to come,” said Amanda Pritchard, NHS England’s chief executive. Read full story Source: The Guardian, 12 October 2022 Further hub reading Genetic profiling and precision medicine – the future of cancer treatment
  13. News Article
    A nurse murdered seven babies and attempted to kill 10 others by poisoning them on a hospital neonatal unit where she was a “constant malevolent presence”, a court has heard. Lucy Letby, 32, fatally injected newborns with insulin, air or milk during night shifts when she knew their parents would not be present, a jury was told. One of the babies was just 24 hours old when Letby allegedly injected him with air, killing him just 90 minutes after she came on shift. The nurse tried to kill his twin sister the next day, it is alleged. The court was told that Letby, who was trained to care for the most seriously ill babies, developed an “unusual interest” in the parents of some of her 17 alleged victims and in some cases tracked them on Facebook. Jurors were told that she was the only “common denominator” that connected the deaths of seven infants and the “catastrophic” collapses of 10 others at the Countess of Chester hospital between June 2015 and June 2016. She allegedly tried to kill some babies more than once – in one case, three times – using various methods. Nick Johnson KC, prosecuting, told the jury: “We say the collapses and deaths of the 17 children named on the indictment were not normally occurring tragedies. They were all the work, we say, of the woman in the dock who we say was a constant malevolent presence when things took a turn for the worse for these children.” Read full story Source: The Guardian, 10 October 2022
  14. News Article
    An appeal to establish a dedicated Mother and Baby Perinatal Mental Health Unit will be delivered to the Nothern Ireland health minister later. Individual women, charities and other organisations will hand over a public letter urging Robin Swann to act. Northern Ireland is the only place in the UK which has no dedicated in-patient service for women with serious post-partum mental health issues. The units admit mothers with their babies so that they can be with them. About 70 women a year in Northern Ireland are admitted to hospital with post-partum psychosis. The health minister approved some funding for perinatal mental health last year. However, no decision has been made on in-patient services. Read full story Source: BBC, 10 October 2022
  15. Content Article
    This article tells the story of Lyndsey, who was 36 years' old and expecting her third child when she died of shock and haemorrhage, and a perforated gastric ulcer. Sadly, her baby also died as a result of Lyndsey's condition. In her narrative report, the Coroner raised concerns that Lyndsey had been prescribed methadone with no face-to-face consultation, and that she had received a prescription with no planned medical review. She also raised concerns about the reliability of the ambulance pre-alert system due the absence of systems for auditing the effectiveness and reliability of the pre-alert system and the lack of knowledge and training of staff in control.
  16. Content Article
    This article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
  17. Content Article
    This article tells the story of Baby E, who died two hours after delivery following issues with the management of her labour. The maternity unit was short-staffed on the night of Baby E's birth and there were delays in getting her mother to theatre for a caesarean section. Baby E's parents felt that the hospital withheld information from them, failing to inform them of internal investigations that had taken place following Baby E's death. At the inquest, the coroner concluded that errors had been made, including the fact that Baby E's low heart rate had been missed. She also criticised the decision-making process in the management of labour, but concluded that she was unable to say whether this had made a difference to whether or not Baby E lived.
  18. News Article
    Hospital authorities in Wales have been accused of attempting to cover up failings in the delivery of a baby born with significant brain damage. Gethin Channon, who was born on 25 March 2019 at Singleton Hospital, in Swansea, suffers from quadriplegic cerebral palsy, a severe disability that requires 24/7 care. There were complications during his birth, due to him being in an abnormal position that prevented normal delivery, and he was eventually born via caesarean section. An independent review commissioned by Swansea Bay University Health Board (SBUHB), which manages Singleton Hospital, found “several adverse features” surrounding Gethin’s delivery that were omitted from or “inaccurately specified” in the hospital’s internal report. The investigation, carried out by obstetrician Dr Bill Kirkup, said SBUHB had “significantly” downplayed the “suboptimal” care received by Gethin and his mother, Sian, and had erroneously attributed his condition to a blocked windpipe. It also suggests that amendments were retrospectively made to examination notes taken by staff during the course of Ms Channon’s labour. The family said that SBUHB, which was flagged by national inspectors in the months after Gethin’s birth due to “concerns” over its ability to deliver “safe and effective” maternity care, had “covered up” the failings in their case. SBUHB said it had been “working tirelessly” with the family to investigate and address their concerns, and that it would be inappropriate to comment on specific allegations as the process was ongoing. Read full story Source: The Independent, 2 September 2022
  19. News Article
    Healthcare Improvement Scotland have been commissioned to lead a review into the neonatal death rates. It follows the higher than expected deaths in both March 2022 and September last year, as published by Public Health Scotland. At least 18 babies under four weeks old died in March – a rate of 4.6 per 1,000 births. The wider inquiry is understood to have been triggered because the mortality rate passed an "upper control" threshold of 4.4 per 1,000 births. The average mortality rate among newborns is just over 2 per 1,000 births. The Scottish Government said the investigation is expected to take no longer than six to nine months once the review team is formed. Public health minister Maree Todd said: “Every death is a tragedy for the families involved. That is why earlier this year I committed to this review to find out if there is a reason for the increase. “I appreciate how difficult this time is for anyone affected and I would encourage them to access support if they wish to do so. There is information about organisations and help available on the National Bereavement Care Pathways Scotland as well as the Scottish Government website.” Read full story Source: The Scotsman, 30 September 2022
  20. Content Article
    Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalisations for jaundice/hyperbilirubinaemia, hypernatraemia/dehydration, and hypoglycaemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide.This article argues that modern misconception of exclusive breastfeeding as natural and thus safe causes common and preventable harm to neonates. This review shows that the evidence regarding common and preventable harm to neonates associated with breastfeeding insufficiencies is sufficient to warrant fundamental changes to early infant feeding policies and practices.
  21. News Article
    A mother from County Down will receive "substantial" undisclosed damages over alleged hospital treatment failures and care given to her daughter. Christina Campbell from Ballygowan brought medical negligence lawsuits over treatment she received at the Ulster Hospital in Dundonald after her daughter, Jessica, died in 2017 with a rare genetic disorder. The claim said that failure to test Ms Campbell during her pregnancy meant the condition went undetected. Damages were also sought for an alleged "ineffective" end of life care plan for the four month old. Jessica was diagnosed with trisomy 13 shortly after her birth in December 2016. She experienced feeding and respiratory difficulties, as well as a congenital heart defect and a bilateral cleft lip and palate. She was discharged from hospital with a home-based end-of-life care plan, including community and respite referral to the hospice, but a few months later. The claims said a failure to provide Ms Campbell with a amniocentesis test, which checks for genetic or chromosomal conditions, meant Jessica's condition was not discovered sooner. The lawsuit also highlighted concerns about Jessica's hospice treatment. It includes alleged uncertainty about the provision of humidified oxygen, a defective feeding pump and delays in a specific feeding plan and saline nebuliser being provided for the family. The family's solicitor said the awarding of damages "signifies the importance of lessons learned" as a result of Ms Campbell's campaign. "It is hoped that lessons can now be learned to ensure no other family has to go through a similar experience," he said. Read full story Source: BBC News, 29 September 2022
  22. Content Article
    An open letter to Brandon Lewis, the justice secretary, and the Sentencing Council for England and Wales warns that pregnant women in jail suffer severe stress and highlights evidence suggesting they are more likely to have a stillbirth. The signatories include the Royal College of Midwives and Liberty.
  23. News Article
    More than half of maternity units in England fail consistently to meet safety standards, BBC analysis of official statistics shows. Health regulator the Care Quality Commission (CQC) rates 7% of units as posing a high risk of avoidable harm. A further 48% require improvement. The figures are slightly worse than a few years ago, despite several attempts to transform maternity care. The regulator says the pace of improvement has been disappointing. In most cases, pregnancy and birth are a positive and safe experience for women and their families, says the CQC. But when things do go wrong, it is important to understand what happened and whether the outcome could have been different. Laura Ellis lost her newborn son when he was unexpectedly breech during advanced labour. She checked out the CQC rating of her local hospital, Frimley Park, when she was pregnant. Maternity services were good. But Laura didn't realise the unit had been told that it required improvement on safety. Laura said: "It was just so hard. So hard to deal with. So hard to leave as well. How would you leave your baby in hospital when you should be taking them home?" Frimley Park NHS Foundation Trust says it has made a number of changes since Theo died, including an emergency response if a baby is unexpectedly breech during advanced labour. Read full story Source: BBC News, 21 September 2022
  24. News Article
    Moments after unveiling a bill that would ban all abortions in the United States at 15 weeks, US Senator Lindsey Graham was interrupted by a mother with a devastating story. "I did everything right and at 16 weeks we found out that our son would likely not live," Ashbey Beasley told a crowded room. "When he was born, for eight days he bled from every orifice of his body," she said. But, she said, at least she got to choose how to handle her difficult pregnancy, while Mr Graham's law would take away that choice. "What do you say to someone like me?" Since the Supreme Court struck down Roe v Wade this summer, states across the US have pushed through abortion bans or severely restricted the procedure. But as such laws have gone into effect, unintended consequences have followed. Doctors and patients say that confusing standards and the vague language of these laws have had a chilling effect on the medical field in anti-abortion states, leaving tragedies in their wake - and more in the making. For the last year, Amanda Horton, a Texas doctor who specialises in high-risk pregnancies, has struggled to care for patients with pregnancy complications. At times, Dr Horton must inform families that their babies have been diagnosed with a fatal foetal anomaly. These conditions are rare and likely to lead to the death of a foetus in utero, or shortly after birth. But under a strict abortion ban in Texas, her hands are tied. Read full story Source: BBC News, 17 September 2022
  25. News Article
    The midwife leading a review into failings by Nottingham's maternity services said the scope was wider than the UK's biggest maternity scandal. Donna Ockenden previously led the review at Shrewsbury and Telford NHS Trust that found failings led to the deaths of more than 200 babies. The terms of reference for the review in Nottingham were set out on Tuesday. A category of severe maternal harm has been added to include cases that did not lead to a death or injury. Earlier this year Ms Ockenden completed her inquiry into the UK's biggest maternity scandal at Shrewsbury and Telford NHS Trust. She said the scope of the review in Nottingham was wider because an additional category had been added to the investigation. It aims to identify cases of severe maternal harm, like an unexpected admission to intensive care or a major obstetric haemorrhage. Ms Ockenden said: "We felt adding in the category of severe maternal harm would help us to understand women's experiences and help us to learn and help the trust to learn from those cases as well. "So actually there's been a widening of the scope which our review team felt was important and when we tested it out with some families they felt it was important too. "Perhaps there's a mum out there saying 'well I'm ok, and my baby's ok, but x,w,z of my maternity experience really worried me or frightened me' then she can send in her experiences." She said fathers could also send in their experiences. Read full story Source: BBC News, 14 September 2022
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