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Found 816 results
  1. Content Article
    The Scottish Patient Safety Programme (SPSP) is a national quality improvement programme that aims to improve the safety and reliability of care and reduce harm.  Since the launch of SPSP in 2008, the programme has expanded to support improvements in safety across a wide range of care settings including Acute and Primary Care, Mental Health, Maternity, Neonatal, Paediatric services and medicines safety. Underpinned by the robust application of quality improvement methodology SPSP has brought about significant change in outcomes for people across Scotland. 
  2. 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
  3. Content Article
    Women and birthing people from black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey. Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what could be done to improve local services. This is the first in a series of blogs published by the Health Innovation Network, reflecting on the learnings and experiences from her Fellowship.
  4. Content Article
    In this book, Sandra Igwe shares her journey as a young Black mother, coping with sleepless nights, anxiety and loneliness after the birth of her first daughter. Burdened by cultural expectations of the 'good mother' and the 'strong Black woman' trope, her mental health struggles became an uphill battle. Black women are at higher risk of developing postnatal depression but are the least likely to be identified as depressed. Sharing the voices of other mothers, Sandra examines how culture, racism, stigma and a lack of trust in services prevent women getting the help they need. Breaking open the conversation on motherhood, race, and mental health, she demands that Black women are listened to, believed, and understood.
  5. 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
  6. 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
  7. News Article
    A hospital has stopped using gas and air in its maternity unit to "protect our midwifery and medical team". The Princess Alexandra Hospital in Harlow, Essex, said the decision followed tests on nitrous oxide levels. It said it would temporarily suspend the use of Entonox while additional safety equipment was installed. Giuseppe Labriola, director of midwifery, said: "There is no risk to mothers, birthing people, their partners and babies." Other hospitals have previously temporarily suspended the use of gas and air in recent months including Basildon and Ipswich. Read full story Source: BBC News, 22 January 2023
  8. News Article
    The health trust behind the worst maternity scandal in NHS history has accepted responsibility for a boy's brain injury. Adam Cheshire, 11, contracted a Group B Strep (GBS) infection following his birth at the Royal Shrewsbury Hospital in 2011. A High Court judge approved a pay out from Shrewsbury and Telford Hospitals NHS Trust (SaTH) to provide special care for the rest of his life. His case was examined as part of senior midwife Donna Ockendon's investigation into SaTH which found catastrophic failures might have led to the deaths and life-changing injuries of hundreds of babies, as well as the deaths of nine mothers. Adam, from Newport, Shropshire, was born nearly 35 hours after his mother's waters broke in the afternoon of 24 March 2011. In the hours that followed, he began to show signs of early onset GBS including struggling to feed, crying and grunting. After weeks in intensive care, he was finally diagnosed with the infection and meningitis. Adam is living with multiple conditions including hearing and visual impairments, autism, severe learning difficulties and behavioural problems so he relies on others to care for him. His mum, the Reverend Charlotte Cheshire, said she had expressed concerns about bright green discharge at one of her last antenatal appointments but no action was taken. "From that point I just had a mother's instinct something wasn't right but I was reassured by the midwives so many times that everything was OK," the 45-year-old said. Mrs Cheshire added: "While Adam is adorable and I am so thankful to have him in my life, it's difficult not to think how things could have turned out differently for him if he'd received the care he should have. "Adam will never live an independent life and will need lifelong care. While I'm devoted to him, I'm now raising a severely disabled son, which is extremely challenging and has changed the path of both our lives forever". Read full story Source: BBC News, 23 January 2023
  9. News Article
    Inspectors raised serious concerns around leadership and safety at Lister Hospital in Stevenage, run by East and North Hertfordshire Trust, when they visited in October. The maternity service was also rated inadequate for leadership. The CQC also raised concerns about staffing shortages, infection prevention control, care records, cleanliness, waiting times and training. The inspection did, however, find staff worked well together, managers monitored the effectiveness of the service and findings were used to make improvements. Carolyn Jenkinson, the CQC’s head of hospital inspection, said: “This drop in quality and safety was down to insufficient management from leaders to ensure staff understood their roles, and to ensure the service was available to people when they needed it.” Read full story (paywalled) Source: HSJ, 20 January 2023
  10. Content Article
    The Health and Social Care Select Committee have published a new report reviewing 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. This blog sets out Patient Safety Learning’s reflections on this report.
  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
    Staff at a maternity unit were exposed to almost 30 times the legal workplace exposure limit for nitrous oxide, documents have shown. Testing at Basildon Hospital revealed the levels more than 16 months before colleagues were informed. The Royal College of Midwives said its members there were considering legal action. Routine testing of the maternity suite in June 2021 revealed nine staff members had been exposed to excess nitrous oxide levels during the course of their shifts. Three had readings of more than 1,000 parts per million (ppm) of the gas, while a fourth recorded almost 3,000. The Workplace Exposure Limit is set at 100ppm. Trust management apologised after failing to notify staff at the unit until October 2022. A briefing seen by the BBC stated the issue was logged on the risk register, but "there has not been proper oversight of the problem and staff have not been informed". One person familiar with the situation, who did not want to be identified, said: "We had an email sent out that said 'emergency maternity staff briefing' and there was a Teams meeting. "The Teams meeting was very, very difficult to listen to. It was very emotive. People were angry understandably, but I feel like the executive who were on the call didn't handle it very well." Read full story Source: BBC News, 16 January 2023
  14. News Article
    Fewer women who gave birth in NHS maternity services last year had a positive experience of care compared to 5 years ago, according to a major new survey. The Care Quality Commission’s (CQC) latest national maternity survey report reveals what almost 21,000 women who gave birth in February 2022 felt about the care they received while pregnant, during labour and delivery, and once at home in the weeks following the arrival of their baby. The findings show that while experiences of maternity care at a national level were positive overall for the majority of women, they have deteriorated in the last 5 years. In particular, there was a notable decline in the number of women able to get help from staff when they needed it. Many of the key findings from the survey include a drop in positive interactions with staff and lack of choices about the birth. Just over two-thirds of those surveyed (69%) reported 'definitely' having confidence and trust in the staff delivering their antenatal care. Results were higher for staff involved in labour and birth (78%). In addition, while the majority of women (86%) surveyed in 2022 said they were 'always' spoken to in a way they could understand during labour and birth, this was a decline from 90% who said this in 2019. The proportion of respondents who felt that they were 'always' treated with kindness and understanding while in hospital after the birth of their baby remained relatively high at 71%, however had fallen from 74% in 2017. Just under a fifth of women who responded to the survey (19%) said they were not offered any choices about where to have their baby. Also, less than half (41%) of those surveyed said their partner or someone else close to them was able to stay with them as much as they wanted during their stay in hospital. Read full story Source: Medscape, 13 January 2023
  15. Content Article
    This survey from the Care Quality Commission (CQC) looked at the experiences of women and other pregnant people who had a live birth in early 2022.
  16. News Article
    The Care Quality Commission (CQC) has sounded the alarm over a “concerning decline” in women’s experiences with maternity services. Fewer women feel they always got the help they needed during labour and birth, many were disappointed at the amount of time their partners could stay with them after the delivery of their babies, and a significant number reported that they did not feel listened to when they raised concerns. The CQC said it has noticed a “deterioration” over the last five years in the ratings women gave their care. It came as a major new national poll showed a “statistically significant downward trend” on most measures examined to track maternity care across the country. In particular, concerns were raised about staff availability, confidence and trust, as well as kindness and understanding of staff. Ratings also tumbled for whether women felt they had been treated with dignity and respect, the amount of information provided to mothers, and their concerns about being listened to. Victoria Vallance, from the CQC, said: “These results show that far too many women feel their care could have been better. This reflects the increasing pressures on frontline staff as they continue in their efforts to provide high-quality maternity care with the resources available.” Read full story Source: The Guardian, 11 January 2023
  17. Content Article
    Globally, the under-five mortality rate (U5MR) fell to 38 deaths per 1,000 live births in 2021, while under-five deaths dropped to 5.0 million. Although this demonstrates a decrease, this immense, intolerable and mostly preventable loss of life was carried unequally around the world , and children continue to face widely differing chances of survival based on where they are born. In contrast to the global rate, children born in sub-Saharan Africa are subject to the highest risk of childhood death in the world with a 2021 U5MR of 74 deaths per 1,000 live births – 15 times higher than the risk for children in Europe and Northern America and 19 times higher than in the region of Australia and New Zealand This report outlines and analyses figures from The United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME) to examine levels and trends in child mortality around the world during 2022.
  18. News Article
    Five million children worldwide died before their fifth birthday in 2021, with almost half (47%) dying during their first month, according to new UN figures. Most of the deaths could have been prevented with better healthcare, say campaigners, adding that deaths among newborn babies haven’t reduced significantly since 2017. Children born in sub-Saharan Africa are 15 times more likely to die in childhood than children in Europe and North America. UN figures also show that 1.9 million babies were stillborn during 2021, more than three-quarters (77%) in sub-Saharan Africa and in south Asia. The risk of a woman having a stillborn baby in sub-Saharan Africa is seven times greater than for women in Europe and North America. Read full story Source: The Guardian, 10 January 2022
  19. 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
  20. 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
  21. Content Article
    This is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
  22. News Article
    A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section. For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame. "It was just continuous lies," the 34-year-old told BBC News. East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned". Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust which reported this year. Read full story Source: BBC News, 9 December 2022
  23. News Article
    NHS England is raiding a national fund earmarked for improvements in cancer, maternity care and other priority services by up to £1bn this year, to pay for deficits elsewhere, and will cut it by a similar amount in 2023-24, HSJ has learned. The “service development fund” is allocated at the beginning of the year for priority service areas also including primary care, community health, mental health, learning disabilities and health inequalities. Several NHSE directors said it was being tightly squeezed this year, amid major cost pressures from inflation, a pay deal unfunded by government, and higher than expected covid-related costs. One well-placed source said the fund this year was required to underspend by about £1bn against what had been planned, which will help balance overspends elsewhere in the NHS. The cuts are likely to be linked to ministers’ view that the NHS should focus on “core” priorities and cut other activities, including reducing NHSE national programme work which is typically linked to SDF budgets. Patricia Hewitt is looking into giving integrated care systems more “autonomy” from NHSE to set their own priorities. Read full story (paywalled) Source: HSJ, 8 December 2022
  24. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
  25. Content Article
    Paul Batalden is the host of "The Power of Coproduction". Prepared as a pediatric physician, he has been an international architect, teacher, and advocate for the improvement of healthcare services for five decades. His current focus is the coproduction of healthcare services.
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