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News Article
East Kent baby deaths: Scale of deaths at trust 'not clear-cut'
Patient Safety Learning posted a news article in News
The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined. Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10. Ms Acott said some of the baby deaths were "not as clear-cut". A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect. Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019. Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white". Read full story Source: BBC News, 12 February 2020 -
News ArticleAn NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth. The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”. Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour. After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”. Read full story Source: The Independent, 13 February 2020
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News Article
East Kent baby deaths: Four more families come forward
Patient Safety Learning posted a news article in News
A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services. Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford. The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case. The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January. Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths. In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly". "We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added. Read full story Source: BBC News, 10 February 2020 -
News Article
Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal
Patient Safety Learning posted a news article in News
The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020 -
News Article
Health secretary to investigate allegations of women denied epidurals
Patient Safety Learning posted a news article in News
Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony. Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader. An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE). Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected. “Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said. “It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.” One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable." Read full story Source: The Telegraph, 26 January 2020 -
News Article
Justice is being denied to too many families
Patient Safety Learning posted a news article in News
Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020 -
News Article
East Kent hospitals: Care watchdog inspects trust after baby death apology
Patient Safety Learning posted a news article in News
England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020 -
News Article
East Kent hospitals: Baby deaths 'could have been prevented'
Patient Safety Learning posted a news article in News
At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found. Significant concerns have been raised about maternity services at the trust. East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care". The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems. In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines. It highlights consultants who: failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested rarely attended CTG training were reported "as doing their own thing rather than follow guidelines". Read full story Source: BBC News, 23 January 2020 -
Content ArticleThis report by the charity Maternity Action looked at the lived experience of pregnant women seeking asylum in the UK. It highlights that pregnant women face barriers in accessing appropriate housing and nutrition during pregnancy, and that midwives and voluntary sector organisations play an important role in supporting pregnant women seeking asylum.
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Content Article
Maternity Action - Dignity in pregnancy
Patient-Safety-Learning posted an article in Maternity
This video by the organisation Maternity Action looks at the impact of UK Border Agency policies on pregnant women seeking asylum. The video highlights the unique challenges faced by women in this situation, including the risk of sudden deportation, lack of rights and mental health issues associated with trauma and lack of perinatal support. Two women share their stories of being pregnant and having young babies while in the asylum system. -
Content ArticleThis report represents the views of organisations and experts who responded to the Department of Health & Social Care's call for evidence on its Women's Health Strategy. The call for evidence was released in March 2021. This report focuses on submissions received from 436 organisations and individuals with expertise in women’s health, including the charity sector (34%), academia (22%), industry (10%), clinicians (7%), professional bodies (7%), pressure groups (7%), NHS organisations (3%), parliamentary groups (2%), royal colleges (1%), local government (1%), think tanks (1%) and others (6%).
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Content ArticlePreventable harm continues to occur to critically ill premature babies, despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. This article in the Journal for Healthcare Quality describes the introduction of a robust process improvement (RPI) program at a NICU in a US children's hospital. Leaders, staff, and parents were trained in RPI concepts and tools and given regular mentoring for their improvement initiatives, which focused on central line blood stream infections, very low birth weight infant nutrition and unplanned extubations. The authors conclude that implementing the RPI program resulted in significant and sustainable improvements to reduce harm in the NICU.
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Content ArticleThe Safety Culture Programme for Maternity & Neonatal Board Safety Champions was commissioned by NHSE/I Women’s Health Policy team. The programme was co-designed with stakeholders including Board Safety Champions, Leaders from the Maternity and Neonatal system and Maternity Voices Partnership through March 2021. The programme is underpinned by the NHSE/I framework developed by the Maternity Transformation Programme Board. The aim of the framework and the programme (concluded on 25 March 2022) is to create the conditions for a culture of safety and continuous improvement across perinatal services to improve the quality, safety and experience of care. View the presentation slides from the recent Aqua event and an overview of the HSIB Investigation Programmes highlighting the differences between the National Investigations Programme and the Maternity Investigations Programme.
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Content ArticleSharon Hartles is a critical criminologist and member of the Open University’s Harm and Evidence Research Collaborative. In this article, Sharon reflects on the significant impact of the harm caused by Primodos, a widely used hormone pregnancy test prescribed to women in the UK between 1958 and 1970. Primodos is now known to cause miscarriage, stillbirth and birth defects, and this article examines the culture of denial and an absence of state and corporate pharmaceutical accountability that allowed patients to continue to be harmed over decades.
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Content ArticleThe Department for Health and Social Care (DHSC) launched a call for evidence in March 2021 to inform the first-ever government-led Women’s Health Strategy for England. This report focuses on the survey component of the consultation. Nearly 100,000 people in England got in touch to share: their personal views and experiences as a woman the experiences of a female family member, friend or partner their reflections as a self-identified health or care professional. The results highlight priority areas for action and further research and underpin DHSC’s vision statement for England’s Women’s Health Strategy (published in December 2021). The full strategy will be published in spring 2022.
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Content ArticleIn this blog for Refinery 29, journalist L'Oréal Blackett discusses the additional risk and associated worries faced by black pregnant women in the UK. With black women four times more likely to die in childbirth than white women, and 40% more likely to suffer a miscarriage, she examines what action the government is taking to improve outcomes for black women and their babies. She speaks to a number of campaigners who highlight the importance of including black women at every stage of research and policy to tackle race-based health inequalities, and who question whether this is being done by the UK government's new Maternity Disparities Taskforce. She also argues that empowering women to make informed, evidence-based decisions is the most effective way to improve maternal safety for black women.
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Content ArticleThe newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
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Content ArticleThis analysis by Paul Gallagher, Health Correspondent at i News discusses the prevalence of maternity scandals in the NHS, in light of the publication of the Ockenden Review into failings in maternity services at Shrewsbury and Telford NHS Trust. He highlights the importance of implementing the findings of the review, particularly focusing on the need for a comprehensive plan to tackle workforce shortages. He also highlights the continued existence in some trusts of a culture of covering up harm, evidenced by staff at Shrewsbury being pressured not to talk to investigators, right up until the report's publication.
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Content ArticleThis report presents the findings and conclusions of an independent review into clinical governance arrangements within maternity services at The North West London Hospitals NHS Trust. The independent review was set up following three maternal deaths in one year and two other serious untoward incidents (SUIs) in the Trusts's maternity unit.
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Content ArticleThis investigation by the Healthcare Commission examined the cases of ten women who died during pregnancy or within 42 days of delivery at Northwick Park Hospital, North West London Hospitals NHS Trust, between April 2002 and April 2005. This number of maternal deaths was significantly higher statistically when compared with other trusts that serve similar populations.
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Content ArticleIn March 2015, Bill Kirkup published his report on avoidable harm in maternity services at the Morecambe Bay NHS Trust. His introduction carried a warning: “It is vital that the lessons, now plain to see, are learnt... by other Trusts, which must not believe that ‘it could not happen here.’” With the publication of the Ockenden report, we now know that one of those other Trusts was the Shrewsbury and Telford NHS Hospital Trust. “For more than two decades,” Donna Ockenden wrote, “they [famiies] have tried to raise concerns but were brushed aside, ignored and not listened to.” But why should patients and families have had to show that kind of courage in the first place? Instead of seeing patient feedback as a foundation stone of high quality, evidence based care, healthcare providers too often see it as a threat writes Miles Sibley in this BMJ Editorial.
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Content ArticleThis is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
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Content Article
In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).- Posted
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Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content ArticleJail can never be a safe place to be pregnant but the flouting of rules makes things worse. No woman should suffer as I did, writes Anna Harley in this Guardian article.
