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Content ArticleOn 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
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Content ArticleThis is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
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Content ArticleThis 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.
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Content ArticlePaul 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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Content ArticleMaternal Mortality Review Committees (MMRCs) in the US are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within a year of pregnancy. MMRCs have access to clinical and non-clinical information to more fully understand the circumstances surrounding each death, determine whether the death was pregnancy-related, and develop recommendations for action to prevent similar deaths in the future. This article summarises the data from MMRCs in 36 US states between 2017 and 2019, demonstrating variations in prevalence and cause of death according to race, ethnicity and geographical area. The data suggests that over 80% of pregnancy-related deaths examined were determined to be preventable.
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Content ArticleKeeping patients safe during their care and treatment should be at the heart of any health system, including the NHS. Yet avoidable harm still occurs every day, around the world. There have been major efforts to prioritise patient safety in England, but the pandemic has shone a light on areas of care where progress has stalled, or safety has deteriorated. This report by Imperial College London's Institute of Global Health Innovation, commissioned by Patient Safety Watch, brings together publicly available data to present a national picture of patient safety in England.
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Content ArticleThis article for Vogue explores the experience of a midwife working in an overstretched maternity unit in England. Melissa Newman, who has been a midwife for nearly six years, highlights the impact of staff shortages on midwives—she describes how she does not have time to eat, avoids drinking because she will not have time to go to the toilet, and sometimes works fifteen hours without any break. She calls on the Government for more funding to fix the crisis facing NHS maternity services, and the NHS more widely.
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News Article
Care substandard at 39% of maternity units in England, NHS watchdog finds
Patient Safety Learning posted a news article in News
Two out of five maternity units in England are providing substandard care to mothers and babies, the NHS watchdog has warned. “The quality of maternity care is not good enough,” the Care Quality Commission (CQC) said in its annual assessment of how health and social care services are performing. It published new figures showing it rated 39% of maternity units it inspected in the year to 31 July to “require improvement” or be “inadequate” – the highest proportion on record. Ian Trenholm, the CQC’s chief executive, said maternity services were deteriorating, substandard care was unacceptably common and failings were “systemic” across the NHS. Its latest state of care report said: “Our ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (nine out of 139) now rated as inadequate and 32% (45 services) rated as require improvement. “This means that the care in almost two out of every five maternity units is not good enough.” The report said: “The findings of recent reviews and reports … show the same concerns emerging again and again. The quality of staff training, poor working relationships between obstetric and midwifery teams and a lack of robust risk assessment all continue to affect the safety of maternity services. These issues pose a barrier to good care.” Staff not listening to women during pregnancy and childbirth is a recurring problem, Trenholm said. Their concerns “are not being heard” by midwives and obstetricians “in the way that they should”. Read full story Source: The Guardian, 21 October 2022 -
News Article
Expert advisers urge FDA to pull pregnancy drug from market
Patient-Safety-Learning posted a news article in News
An expert panel convened by the US Food and Drug Administration voted 14-1 on Wednesday to recommend withdrawing a preterm pregnancy treatment from the market, saying it does not work. During the sometimes contentious three days of hearings, the drugmaker Covis Pharma, backed by some clinicians and patient groups, had argued there is evidence to suggest the drug, called Makena, might work in a narrower population that includes Black women at high risk of giving birth too soon. But FDA experts and others said the data does not support such a view. In closing arguments, Peter Stein, director of the Office of New Drugs at the FDA’s Center for Drug Evaluation and Research, agreed on the urgent need for a drug to reduce the incidence of preterm birth — a leading cause of infant mortality in the United States. But he said the data indicates that Makena is not that drug. Stein said, “Hope is a reason to keep looking for options that are effective,” he said. “Hope is not a reason to take a drug that is not shown to be effective, or keep it on the market.” Read full story Source: The Washington Post, 19 October 2022 -
News Article
East Kent NHS inquiry finds better care might have prevented 45 babies’ deaths
Patient Safety Learning posted a news article in News
The deaths of at least 45 babies could have been avoided if nationally recognised standards of care had been provided at one of England’s largest NHS trusts, a damning inquiry has found. Dr Bill Kirkup, the chair of the independent inquiry into maternity at East Kent hospitals university NHS foundation trust, said his panel had heard “harrowing” accounts from families of receiving “suboptimal” care, with mothers ignored by staff and shut out from discussions about their own care. The inquiry’s report said: “An overriding theme, raised with us time and time again, is the failure of the trust’s staff to take notice of women when they raised concerns, when they questioned their care, and when they challenged the decisions that were made about their care.” Of 202 cases reviewed by the experts, the outcome could have been different in 97 cases, the inquiry found. In 69 of these 97 cases, it is predicted the outcome should reasonably have been different and it could have been different in a further 28 cases. Of the 65 babies’ deaths examined, 45 could have had a different outcome if nationally recognised standards of care had been provided. In nearly half of all cases examined by the panel, good care could have led to a different outcome for the families. Some of the bereaved parents accused the trust of “victim blaming” mothers for their children’s deaths. Kelli Rudolph and Dunstan Lowe, whose daughter Celandine died at five days old, said: “Doctors sought to blame Kelli for Celandine’s death. This victim blaming was the first in a long line of interactions with those in the trust who sought to delay, deflect and deny our search for the truth about what happened to our baby. “In isolation, these tactics traumatised us after the tragedy of our daughter’s death. But when seen in the light of 10 years of failures, they signal a concerted effort to cover up the trust’s responsibility for what happened to Celandine and the many others who lost their lives due to failures in clinical judgment.” Read full story Source: The Guardian. 19 October 2022 -
News Article
'No-one joined the dots' - grandad who exposed an NHS scandal
Patient Safety Learning posted a news article in News
More than 200 families in south-east England will learn today the results of a major inquiry into the maternity care they received from a hospital trust. The investigation into East Kent Hospitals NHS Trust follows dogged campaigning by one determined bereaved grandfather. Derek Richford's grandson Harry died at East Kent Hospitals after his life support system was withdrawn. Sixty one-year-old Derek had never campaigned for anything in his life. His initial approach was to wait for East Kent Hospitals Trust to investigate the death, as it had promised. However, one nagging issue that was to become central to Derek's view of the trust, was the hospital's continual refusal to inform the coroner of Harry's death. The family repeatedly requested it, but the trust said it was unnecessary as it knew the cause, namely the removal of the life support system. The hospital also recorded Harry's death as "expected" - again because his life support system had been withdrawn. On both points, the family were left confused and increasingly angry. In early March 2018, some four months after Harry's death, the family finally received the outcome of the trust's internal investigation - known as the Root Cause Analysis (RCA). The RCA indicated multiple errors had been made in Harry and Sarah's care and treatment, and his death was "potentially avoidable". Prior to the meeting, Derek wrote to the Kent coroner's office outlining in general the circumstances of Harry's case, asking if that was the type they would expect to be notified of. The email response from the coroner's office was clear. It said: "Based on the facts you have presented, this death should have been reported to the coroner." Despite this, at the meeting with the trust, the lead investigator into Harry's death told the family: "If we have a clear cause of death by and large we do not involve the coroner." The family's insistence eventually paid off - five weeks after that meeting, the trust informed the coroner of Harry's death. While his son and daughter-in-law started trying to recover from the trauma of losing Harry, Derek turned his attention to investigating East Kent, one of the largest hospital trusts in England. "When I started investigating what was going on with Harry, it was very much like peeling back an onion. 'Hang on a minute, that can't be right, that doesn't add up.' Ever since I was a small kid, justice has been so important to me. "What I found was that, up to that point, no-one had ever joined the dots. And that's so important. I think this had to happen, someone had to do it. There will be families before us that wish they did it. We will be saving a level of families after us." Read full story Source: BBC News, 19 October 2022 -
News ArticleThe former lead governor of East Kent Hospitals University Foundation Trust has resigned this morning, claiming there is “a cancer at the top of the organisation” and that its services won’t be safe until the government provides funding for critical estates work. His resignation as a governor came hours before the publication of what is expected to be a “harrowing” report into maternity services at the trust from an independent review led by Sir Bill Kirkup. He is also expected to raise concerns about national progress on maternity services safety in recent years. Alex Lister, who is chair of the council of governors’ membership engagement and communications committee, said in the letter: “I believe officials on six-figure salaries continue to mislead, obfuscate, bully and conceal vital information. I consider the way the trust communicates internally and externally to be completely unacceptable and utterly untrustworthy. “Without the valiant efforts of the brave families caught up in a tragedy of the trust’s making, the world may never have found out about the disastrous health failings at our trust.” In the letter to chair Niall Dickson, Mr Lister says he has seen a continuation “of the same apparent policy of manipulation and discrediting dissenting voices that existed prior to the scandal”. Read full story (paywalled) Source: HSJ, 19 October 2022
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News Article
NHS faces £90bn bill for ‘staggering’ maternity blunders
Patient Safety Learning posted a news article in News
The NHS faces a record £90 billion maternity bill, The Telegraph can reveal ahead of a “harrowing” report into failings at East Kent Hospitals Trust. Official figures show the number of claims have risen by almost one quarter in just two years following a series of scandals. The data show 1,243 maternity negligence claims in 2021/22 - up from 1,015 in 2019/20. Safety campaigners said the figures were “staggering” - with £90 billion now set aside to cover the costs of claims. It means that in total, 70% of total liability provision for NHS negligence is associated with failings in pregnancy and childbirth, amid rising claims. The figure - equivalent to two-thirds of the NHS annual budget - represents an estimate for the total costs if all claims it expects to settle were paid out, at today’s prices. An NHS spokesperson said: “Despite improvements to maternity services over the last decade – with significantly fewer stillbirths and neonatal deaths – we know that further action is needed to ensure safe care for all women, babies and their families. “The NHS is ensuring that work is already underway to make these improvements, including a £127 million investment this year to boost the maternity workforce, strengthen leadership and increase neonatal cot capacity – which is on top of an annual boost of £95 million for staff recruitment and training announced last year.” Read full story (paywalled) Source: The Telegraph, 18 October 2022 -
News ArticleA 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
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News Article
Staff at Kent NHS trust warned of 'harrowing report' into preventable baby deaths
Patient Safety Learning posted a news article in News
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 -
News Article
NHS logging baby deaths as stillbirths ‘to avoid scrutiny’
Patient Safety Learning posted a news article in News
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 -
News Article
University of Leicester team finds more stillbirths in deprived areas
Patient Safety Learning posted a news article in News
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 -
News Article
Why are hospitals still using Covid rules to keep fathers out of maternity wards?
Patient Safety Learning posted a news article in News
At 9.16am Florence Wilkinson gave birth to a healthy baby boy by planned caesarean section. The team of NHS doctors and midwives worked like a well-oiled machine, performing what to them was a standard operation, while also showing real kindness. After a short stint in a close observation bay, Florence was moved onto the postnatal ward. Still anaesthetised, Florence was completely reliant on her partner Ben to help her recover from the birth and feed her son in his first hours of life. Yet just a few hours later, the scene was very different. Due to Covid protocol, Ben was not able to stay overnight. At 8pm, midwives bustled around briskly ejecting fathers and birth partners from the ward – and what followed was one of the hardest, most frightening nights of Florence's life. She was alone with a newborn, yet during the course of that night she only saw a midwife once. She was still recovering from my operation and unable to pick up her baby. An exhausted healthcare assistant told Florence she didn’t have time to help and the newborn didn’t feed for seven hours. There simply weren’t enough staff to look after the mothers, but no partner to advocate for them either. A review of the maternity policies listed on the websites of 90 hospital trusts in England reveals that 54% still restrict partners from staying overnight after birth. While a few trusts have always limited access at night, many admit to bringing in restrictions during the pandemic which they continue to implement to this day. “It is deeply concerning to hear that some Trusts are continuing to implement restrictions on visiting, such as limited postnatal visiting overnight, under the premise of Covid, particularly at this stage in the pandemic,” says Francesca Treadaway, director of engagement at the charity Birthrights. “There is overwhelming evidence, built up since March 2020, of the impact Covid restrictions in maternity had on women giving birth. It must be remembered that blanket policies are rarely lawful and any policies implemented should explicitly consider people’s individual circumstances.” Read full story (paywalled) Source: The Telegraph, 13 October 2022 -
News Article
‘Obfuscations and failures’ in trust’s handling of death, damning review finds
Patient Safety Learning posted a news article in News
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 -
News Article
NHSE drops tech target
Patient Safety Learning posted a news article in News
NHS England has revealed it is no longer planning to meet a long-term plan maternity digitisation target, because of a change of approach. Under the heading of “empowering people”, the 2019 long-term plan promised to extend digital access to maternity records to the whole country by 2023-24. This was in addition to digitising the so-called red book, which is used to track the health of babies and young children. It followed a recommendation in the 2016 Better Births report, led by former health minister Baroness Julia Cumberlege and commissioned by NHS England. It was intended to reduce bureaucracy and improve safety, as well as provide parents with better information. However, a paper prepared by chief nursing officer Ruth May for NHSE’s October board meeting said while the organisation “remains committed” to digitising the records, meeting the 2024 deadline would be a challenge due to “varying levels of digital maturity and change capacity across maternity services”. In response, Royal College of Obstetricians and Gynaecologists president Edward Morris told HSJ: “While we recognise the enormous pressures that maternity services are currently facing, we are disappointed that NHSE is no longer on track to meet the target to digitise maternity records by 2024. “This programme of digitisation will help realise our ambition for more effective use of data collected during pregnancy, to help identify and prevent the future onset of disease and improve outcomes for women and their babies. “If digital maternity records are to become part of the wider shift to electronic patient records, it is vital that this information is still accessible to both women and healthcare professionals as an important tool for shared decision making.” Read full story (paywalled) Source: HSJ, 11 October 2022 -
News ArticleHospital 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
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News Article
Staffing shortages force NHSE to abandon safety target
Patient Safety Learning posted a news article in News
NHS England has this week told trusts it is abandoning a patient safety target ‘until maternity services in England can demonstrate sufficient staffing levels’ to meet it. The Midwifery Continuity of Care model was designed to ensure expectant mothers would be cared for by the same small team of midwives throughout their pregnancy, labour and postnatal care. It was a key recommendation of 2016’s Better Births review of English midwifery services. NHSE’s chief midwifery officer for England Jacqueline Dunkley-Bent championed the policy and guidance on its implementation was issued in October. However, in her report on the care failures at Shrewsbury and Telford Hospital Trust’s maternity department, Donna Ockenden said the Midwifery Continuity of Care model should be suspended until more evidence was gathered about its effectiveness and there were enough midwives to meet minimum staffing requirements. Ms Ockenden said patient safety had been “compromised by the unprecedented pressures that Continuity of Care models of care place on maternity services already under significant strain”. Read full story (paywalled) Source: HSJ, 23 September 2022 -
News Article
Many English maternity units not meeting safety standards
Patient Safety Learning posted a news article in News
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 -
News Article
Staff warned of ‘harrowing’ care standards review
Patient Safety Learning posted a news article in News
Trust staff have been warned that an independent investigation into maternity services will be ‘a harrowing read’ with a ‘profound and significant impact’. The report into services at East Kent Hospitals University Foundation Trust between 2009 and 2020 had been expected to be published on Wednesday 21 September. However, this morning families involved in the investigation received an email saying publication would be postponed to an unknown date in October.. Next Wednesday, when the report was expected to be released and a statement made to Parliament, has been set aside for all MPs to take an oath of allegiance to King Charles III. An email sent to staff at East Kent last week and seen by HSJ said publication would place “significant focus on the trust and all of our services”, and that the trust would make support available to staff as well as former, current and potential patients. The trust will not see the report before publication. The investigation – led by Dr Bill Kirkup, who also led the Morecambe Bay maternity investigation – was prompted by the death of week-old Harry Richford after a traumatic birth at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Around 200 families are thought to have contacted the investigation team with concerns around maternity care. Read full story (paywalled) Source: HSJ, 15 September 2022 -
Content ArticleOn the 20 January 2023 the Health and Social Care Select Committee published a reported with reviewed 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 paper sets out the UK Government’s response to the recommendations set out in this report. Related reading: Health and Social Care Select Committee: Follow-up on the IMMDS report and the Government’s response (20 January 2023) Patient Safety Learning: Response to the Select Committee report on the Independent Medicines and Medical Devices Safety Review (20 January 2023)
