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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) third annual conference took place on 21 September 2022. Presentations and videos from the day are now available to view and download below. Although it tied in with the World Health Organization’s World Patient Safety Day theme of medication safety, our speakers also covered: how we can drive system level change practical sessions based on our HSIB investigation education courses maternity safety insights themed around inclusivity of care opportunities for sharing and learning from Norway’s healthcare safety investigation body, UKOM.
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Content ArticleIn this blog, The Patients Association's Chief Executive Rachel Power argues that the findings of the independent investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust demonstrate the repeated failure of maternity services in England to offer safe and compassionate care to families. She outlines the key findings of the report, including catastrophic failures in the organisation's culture, team working and professionalism, and failure to listen to patients. She highlights that the lack of honesty shown by the Trust to individuals and families harmed by the hospitals' failures is shocking, and compounded the suffering felt by each family.
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Content ArticleIn this BMJ feature, journalist Emma Wilkinson looks at how a shortage of health visitors in England is leaving babies and children exposed to safeguarding risks, late diagnosis and other problems. An estimated third of the health visitor workforce has been lost since 2015, and research by the Parent-Infant Foundation suggests that 5000 new health visitors are needed. Families are not getting the minimum recommended number of contacts with health visitors during the first three years of life, and research into the impact of this on children's outcomes is ongoing. Emma speaks to different mothers, including Phillippa Guillou, who had a baby in 2020 and struggled to breastfeed. Philippa felt unsupported and ignored by her local health visiting service, who only saw her once by videocall when her baby was one year old.
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Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThis debate begins with a statement by the Parliamentary Under-Secretary of State for Health and Social Care, Dr Caroline Johnson MP, regarding the publication of the report of the independent investigation into maternity and neonatal services in East Kent Hospitals NHS Foundation Trust. It is followed by questions from MPs in the chamber and the Minister's responses.
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Content ArticleReports showing that babies and mothers died or were harmed as a result of failures by, and sometimes heartless cruel treatment in, NHS maternity units are becoming worryingly common. Dr Bill Kirkup’s just-published 192-page exposé of an appalling catalogue of failings at East Kent NHS trust between 2009 and 2020 is the second in the last 12 months. As many as 45 babies and 23 mothers in East Kent died avoidably during that time because their care was substandard, his inquiry found. March brought Donna Ockenden’s grim findings about poor maternity care at the Shrewsbury and Telford trust. And Kirkup produced the first detailed exposition of what inadequate care of women and their offspring during childbirth looked like when in 2015 he laid bare “serious and shocking” lapses in care at Morecambe Bay trust. A fourth official inquiry, again being led by Ockenden, is under way into death, brain damage and other horrendous outcomes at the Nottingham trust. Families affected claim that, despite coroners’ findings, close scrutiny of the trust by regulators, media coverage of lapses in care and pressure for change, “babies, mothers and their families continue to be harmed”. No wonder Rob Behrens, the NHS Ombudsman, says: “The phrase ‘never again’ is starting to ring hollow.”
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Content Article'State of Care' is the Care Quality Commission's annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
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Content ArticleThis article by Carrie Murphy looks at the practice of inserting a 'husband stich' or 'daddy stitch', where midwives or obstetricians make an unnecessary extra stitch when repairing episiotomies or tearing from birth. The belief is that it will make the vaginal opening tighter and therefore increase pleasure for the woman's sexual partner. The author highlights that this is a real practice that has been carried out on women for many years, and describes the ongoing impact it can have on women affected, many of whom don't realise they have been given too many stitches. This misogynistic and unethical practice can cause additional pain for women during sex. The women featured in this article state that they did not consent to the practice, being vulnerable after childbirth and in many cases unaware of what a 'husband stitch' was. Angela Sanford reports only finding out that she had a 'husband stitch' five years after birth at a cervical screening appointment where the nurse expressed concern. Murphy expresses her concern that the practice may still be carried out without women's consent, leaving them feeling violated and in pain.
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Content ArticleThis 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.
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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.- Posted
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Content ArticleIn February 2020 the UK Government commissioned Dr Bill Kirkup to undertake a review into maternity and neonatal care services between 2009 and 2020 in two hospitals, the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital (WHH) in Ashford. Both these services fall under the East Kent Hospitals NHS Foundation Trust. The report found that over this period those responsible for these services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor. It identifies four key areas for action which must be addressed to improve patient safety in maternity and neonatal care services.
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Content ArticleHarry Richford was born at the Queen Elizabeth the Queen Mother Hospital (QEQM), Margate, Kent on 2/11/17. He died on 9/11/17 at the William Harvey Hospital, Ashford to where he had been transferred. The cause of death was 1a Hypoxic Ischaemic Brain Encephalopathy. There was a narrative conclusion setting out some seven failures in the care of Harry Richford together with a conclusion that his death was contributed to by neglect.
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Content ArticleMBRRACE-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.
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Content ArticleA 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.
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Content ArticleThis blog by Victoria Vallance, Director of Secondary and Specialist Care at the Care Quality Commission (CQC) discusses how engagement with frontline NHS maternity staff has informed the CQC's inspection approach, and is being used to support improvements in care. She highlights that recent reviews and reports highlight recurring concerns that affect maternity safety: the quality of staff training, poor working relationships between obstetric and midwifery teams, and a lack of robust risk assessment. She then goes on to talk about an event held by the CQC that brought together staff from NHS maternity services across England to discuss the challenges that they face and seek their views on what needs to change to overcome them.
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Content ArticleThis joint report by the APPG on Baby Loss and the APPG on Maternity is a culmination of over 100 submissions to an open call for evidence from staff, service users and organisations, on the maternity staffing crisis. It paints a picture of a service that is at breaking point and staff that are over-worked, burnt out and stressed.
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Content ArticleThis 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.
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Content ArticleThis article tells the story of Ruth, whose baby son was left with severe cerebral palsy and several other injuries following oxygen starvation during his birth. Ruth's labour was badly mismanaged and she found gaps, omissions and additions to her medical notes when she requested copies. Following a lengthy legal case, Kate received compensation that allowed her family to pay for her son's medical and care needs and adapt their home.
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Content ArticleThe Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.
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Content Article
AvMA case study: Lyndsey's story
Patient-Safety-Learning posted an article in Risk management and legal issues
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. -
Content ArticleThis 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.
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Content ArticleEverybody has a right to good care. Much attention is rightly focused on the occasions when people experience poor quality care, but it is also important to recognise where care is good and to celebrate the services that are getting it right. Some care providers do things well through innovative new ways of working, or by doing the basics well. Others can learn from them and solutions should be shared across the system. This publication from the Care Quality Commission (CQC) is purposely focused on celebrating good and outstanding care that CQC's inspectors have seen.
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Content ArticleThis report by Best Beginnings, Home-Start UK and the Parent-Infant Foundation highlights the impact Covid-19 and measures introduced to control its spread have had on babies. It highlights a “baby blindspot” in Covid-19 recovery efforts and a shortage of funding for voluntary sector organisations and core services like health visiting to offer the level of support required to meet families’ needs. The authors of the report spoke to mothers of babies born during the pandemic and surveyed professionals and volunteers who work with babies and their families.
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Content ArticleThis realist evaluation aimed to explore and explain the ways in which a programme initiated by the Scottish Government, Keeping Childbirth Natural and Dynamic (KCND), worked or did not work in different maternity care contexts. KCND was a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm.
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Content ArticleIdentifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk.
