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Found 810 results
  1. News Article
    At least 38 babies died in the space of nine years after serious incidents in the country’s maternity units, it has emerged. The total is based on research of both media reports of inquests and settled claims. Before Christmas, a review by the Irish Examiner revealed 21 hospital baby deaths followed one or more serious incidents, between 2013 and 2021. However, further study in the same nine-year period shows the toll to be higher. The worst year was 2018, when not only did at least 10 babies die, but three of them died at the same Dublin hospital over a five-month period. In at least 18 of the 38 deaths, issues around foetal heartbeat monitoring (CTG) were raised either at inquest or in the High Court. At least 18 of the inquests resulted in a verdict of medical misadventure. As well as issues around heart monitoring, the Irish Examiner review shows that in at least seven of the 38 cases, maternity staff missed signs that a woman was in labour, leading to repeated recommendations around training. In at least seven cases, mothers’ concerns were ignored. Read full story Source: Irish Examiner, 29 December 2023
  2. Content Article
    The Professional Standards Regulatory Body are holding a series of webinars in January 2024 designed for professionals working in or with maternity services where they will review the updated Digital Maternity Record Standard. Each session will focus on different aspects of maternity care.  Having access to the right information at the right time helps professionals make decisions for safer, more personalised care and supports people using services to manage their own information. Health and care professionals, organisations that support people during and after pregnancy, IT system suppliers and people who use maternity services are welcome at these sessions. Find out more about the sessions and how to sign up via the link below.
  3. Content Article
    If you’ve recently used maternity services, or if you’re pregnant at the moment, the Professional Records Standards Body (PRSB) would like to invite you to join one of their online workshops in January 2024. Each session will last no longer than 1 hour 30 minutes and you’ll receive a £25 shopping voucher to thank you for your time if you attend. The PRSB are working with the NHS to improve how information about your health is recorded and shared during your pregnancy and after your baby has been born. This could include information about treatment or advice you’ve received, tests and scans you’ve had or decisions you’ve made about your maternity care.   Find out more about the project, and how to book onto a workshop via the link below.
  4. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme has published an MBRRACE-UK Perinatal confidential enquiry report on a comparison of the care of Black and White women who have experienced a stillbirth or neonatal death. It is based on deaths reviewed in England, Wales, Scotland and Northern Ireland, for the period between 1 July 2019 and 31 December 2019. The overall findings of this enquiry were based on the consensus opinion of panel members concerning the quality of care provided for the 36 Black and 35 White mothers and their babies. This enquiry was developed to try and identify any differences in the quality of care provided to women of Black ethnicity compared with their White counterparts, and forms the main focus of this report. As such, the recommendations are targeted at trying to ensure equity for the quality of care provision for both Black and White mothers and their babies.
  5. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme has published an MBRRACE-UK Perinatal confidential enquiry report that compares the care of Asian and White women who have experienced a stillbirth or neonatal death. It is based on deaths reviewed in England, Wales, Scotland and Northern Ireland, for the period between 1 July 2019 and December 2019. The overall findings of this enquiry were based on the consensus opinion of panel members concerning the quality of care provided for 34 Asian and 35 White mothers and their babies. This enquiry was developed to try and identify any differences in the quality of care provided to women of Asian ethnicity compared with their White counterparts, and forms the main focus of this report. As such, the recommendations are targeted at trying to ensure equity for the quality of care provision for both Asian and White mothers and their babies.
  6. News Article
    Patients have been harmed as a result of doctors striking this year, and others needing time-critical treatment will be at risk during next month’s walkout in England, hospital bosses have said. Cancer patients and women having induced or caesarean section births will be in danger of damage to their health unless junior doctors in those areas of care abandon their plans to strike for six days in January, they said. People awaiting urgent eye surgery risk permanent sight loss unless the British Medical Association (BMA) lets junior doctors keep working in that area, according to NHS Employers, which represents health service trusts in England. Its intervention comes amid mounting concern in the NHS that it may prove impossible to maintain patient safety in high-risk, time-sensitive areas of treatment when tens of thousands of junior doctors stage what will be the longest strike in NHS history from 3 January, when hospitals are facing what is often the service’s busiest week of the year. Read full story Source: The Guardian, 21 December 2023
  7. Content Article
    Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, authors of this study, published in BMJ Quality and Safety, sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk.
  8. Content Article
    This study compared two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO4) uptake in preterm births for the prevention of cerebral palsy. It found that PReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further.
  9. Content Article
    Since the launch of the national Perinatal Mortality Tool (PMRT) in early 2018, over 23,000 reviews have been started. This fifth annual report presents the findings for reviews completed from March 2022 to February 2023 coinciding with the third year of the global health emergency due to the COVID-19 virus.
  10. News Article
    Women in labour at a London maternity unit deemed “inadequate” were left alone with unsupervised support workers who were not given any guidance, an NHS safety watchdog has found. In a scathing report of North Middlesex Hospital’s maternity services, the Care Quality Commission also found examples of delays to induction of birth for women, and one case of a woman with a still-born baby who was left waiting for the unit to call her in for an induction. Inspectors have downgraded the maternity unit from “good” to the lowest possible rating “inadequate” following an inspection earlier this year. Staff reportedly told inspectors they felt they were “criticised” or “bullied” when reporting safety incidents within the unit. “We heard that the criticism or bullying was worse if the incident reported was relative to other staff and their perceived behaviours,” the report said. There was also evidence the hospital was not recording the severity of safety incidents correctly for example two “never events”, which are among the highest category incidents, were categorised as “low harm”. Other findings included women and babies came to harm as the hospitals did not follow standards to language interpretation despite covering a higher than average minority ethnic population. Read full story Source: The Independent, 11 December 2023
  11. News Article
    The expert tasked by government and NHS England to investigate maternity scandals has criticised ministers for failing to provide the funding necessary to address the problems. Donna Ockenden said the funding provided so far was “nowhere near good enough” and progress made to improve services had been “extremely disappointing”. After her investigation into the deaths and harm of 295 babies and nine mothers at Shrewsbury and Telford Hospitals Trust, the Department of Health and Social Care endorsed recommendations to invest an additional £200m to £350m per year into maternity services. IMs Ockenden suggests the recent impact of inflation, pay awards, and other rising costs means the full £350m is required. According to NHSE an additional £165m per year has been invested since 2021, and the DHSC said this would rise to £187m from April. Ms Ockenden, a senior midwife, told HSJ: “What I would like to say loud and clear to the government is that we are broadly 50 per cent of the way there in receiving the money we know is needed for maternity services. That is nowhere near good enough. “There are workforce issues across [the whole team], whether that’s midwives, obstetricians or neonatologists, and it’s hardly surprising. “The government must now do more – whilst we were grateful for the endorsement [of her report], the lack of progress in providing what is known to be the required funding is extremely disappointing.” Read more (paywalled) Source: HSJ, 11 December 2023
  12. News Article
    NHS England has issued a national alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. According to the alert, the Euroking electronic patient record provided by Magentus Software could be displaying incorrect patient information to clinicians. The Euroking EPR is used in the maternity departments of at least 15 trusts according to information held by HSJ. These organisations have been asked to “consider if Euroking meets their maternity service’s needs” and to “ensure their local configuration is safe”. Trusts with different maternity EPR providers have also been asked to reassess the clinical safety of their solutions. The potential “serious risks” relate to a fault in the Euroking EPR which allows new patient information to overwrite previously recorded information, which could lead to “incorrect management of the pregnancy and subsequent harm”. Read full story (paywalled) Source: HSJ, 8 December 2023
  13. Content Article
    Potential serious risks to patient safety have been identified with the use of Magentus Software Limited’s Euroking maternity information system. These concern specific data fields: certain new patient information, recorded during a patient contact, can overwrite ('back copy') information previously recorded in the patient’s pregnancy record. certain pregnancy-level data (information relevant only to a specific pregnancy event) can be saved at a patient level (where information relevant throughout a person's life is recorded), causing new information to overwrite (‘back copy’) previously recorded data across an entire patient record. certain recorded pregnancy-level data can pre-populate into new pregnancy records (‘forward copy’), which can mean clinicians will see incorrect patient information, and attempts to correct this can result in the issue described at (ii) above.
  14. News Article
    NHS figures obtained by Labour reveal 11,507 women sought care but did not get any last year. Almost 20,000 women a year living with mental health problems triggered by being pregnant or giving birth are being denied support by the NHS, the Guardian can reveal. Furthermore, those who do receive mental health help for their trauma are having to wait up to 19 months to start treatment in some parts of England because specialist services are so overstretched. The situation has been described as “an absolute scandal” and sparked warnings that “rationing” of such vital care could leave women who do not get it in a very vulnerable state and risk their children facing lifelong health problems and stop mothers bonding with their baby. Read full story Source: Guardian, 5 December 2023
  15. Content Article
    Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear. The aim of this study from Mary Dixon-Woods and colleagues was to identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010–2023, and to conduct a structured quality assessment. They found poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.
  16. News Article
    The management of fragile maternity services is being hamstrung by a lack of clear standards and direction from government and regulators, trust chairs and chief executives have told HSJ. Kathy Thomson, the retiring chief executive of Liverpool Women’s Foundation Trust, told HSJ that a major overhaul of regulation and oversight of maternity care was needed. She warned that trust leaders were confused about what was expected of their stewardship of maternity services. Much of the increased scrutiny of the sector was coming from people with little knowledge and experience of maternity care, and maternity was beset by too many initiatives which “somebody thinks are a nice thing to do”. Ms Thomson’s comments were echoed by a wide range of other NHS leaders (see ’damaging confidence’ below). Ms Thomson told HSJ: “How clear are we nationally about the real ask of maternity services? Are we going to say it’s the ten NHS Resolution (NHSR) safety standards, which are really tough to achieve and which we agonise over? Or is it the CQC standards, because they will often take a different view around very similar issues? “We’ve had that this year after we’ve been assessed as compliant by NHSR, but then had to re-provide evidence after we’ve been criticised by the CQC for something… and then NHSR have written back to say we’re still fully compliant. “So, should you put your time and energy into the NHSR standards, or do you spend the time on the more subjective drivers? Because we can’t keep doing all of it and having different parts of the NHS saying this is what you need to do or expecting something different.” Read full story (paywalled) Source: HSJ, 30 November 2023
  17. News Article
    Parents of a two-day-old girl who died in hospital after an emergency C-section are calling for a national inquiry into maternity services. Abigail Fowler Miller died at Brighton's Royal Sussex County Hospital (RSCH), in January last year. On 21 January 2022, Mr Miller and Katie Fowler contacted the hospital's maternity assessment unit four times during the day. Their first phone call was to inform the maternity assessment unit Ms Fowler was in labour, then to report bleeding, and finally to tell them she had become faint and short of breath. According to the Health Safety Investigation Branch's (HSIB) report, staff recorded that Ms Fowler sounded "distressed" in the fourth phone call to the unit, and she thought she was having a panic attack. Staff said she could not answer questions in the fourth phone call because of her "distressed state" and she was asked to come into the hospital. Ms Fowler went into cardiac arrest on the journey in a taxi due to a uterine rupture. An inquest last week found her life would have been prolonged if her mother had been admitted to hospital sooner. In October, families whose babies have died or been harmed in the care of the NHS called for a statutory public inquiry into England's maternity services. Robert Miller, Abigail's father, told BBC Newsnight: "A national inquiry is the only way forward - we cannot continue to treat every incident as a separate tragedy." Read full story Source: BBC News, 28 November 2023
  18. News Article
    Almost half of all English maternity units are offering substandard care, making it one of the worst performing acute medical services in the NHS, Byline Times analysis has found. The analysis, based on inspections of English hospitals by the Care Quality Commission (CQC), found that 85 of 172 inspected maternity services in England received ratings of ‘inadequate’ (18) or ‘requires improvement (67) at their latest inspection. Some 65% of maternity wards were given subpar ratings for patient ‘safety’ one of several metrics looked at by the CQC. The findings come after the health regulator began a focused inspection programme of maternity wards last year after the a government review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by shoddy care. In one unit at Gloucestershire Royal Hospital, there was a shortage of midwives, not all medicines practices were safe which “potentially placed women at risk of harm” and serious incidents were not being investigated. The report found a backlog of 215 patient safety incidents that had not yet been looked into, as of March this year. Maria Caulfield, Minister for Women’s Health Strategy, told Byline Times that “maternity care is of the utmost importance to this Government” and stressed they have “invested £165 million a year since 2021 to grow the maternity workforce and improve neonatal services”. “Every parent must be able to have confidence in the care they receive when giving birth, and we are working incredibly hard to improve maternity services, focusing on recruitment, training, and the retention of midwives,” she added. Read full story Source: Byline Time, 28 November 2023
  19. Content Article
    The latest Care Quality Commission (CQC) report on the state of care in England is far from an encouraging read.1 Although the healthcare system is under serious strain, maternity services are among the areas identified as especially challenged. The problems identified in maternity care, while shocking, come as no surprise. The sector is seeing repeated high profile organisational failures and soaring clinical negligence claims, together with grim evidence of ongoing variation in outcomes, culture, and workforce challenges and inequities linked to socioeconomic status and ethnicity. In this BMJ Editorial, Mary Dixon-Woods and colleagues discuss why it's time for a fresh approach to regulation and improvement.
  20. News Article
    Calls are being made to improve NHS interpreting services, with staff resorting to online translation tools to deliver serious news to non-English speaking patients. The National Register of Public Service Interpreters said "poorly managed" language services are "leading to abuse, misdiagnosis and in the worst cases, deaths of patients". The BBC's File on 4 programme has found interpreting problems were a contributing factor in at least 80 babies dying or suffering serious brain injuries in England between 2018 and 2022. NHS England says it is conducting a review to identify if and how it can support improvements in the commissioning and delivery of services. Rana Abdelkarim and her husband Modar Mohammednour arrived in England after fleeing conflict in Sudan, both speaking little English. It was supposed to be a fresh start but they soon suffered a devastating experience after Ms Abdelkarim was called to attend a maternity unit for what she thought was a check-up. In fact, she was going to be induced, something Mr Mohammednour said he was completely unaware of. "I heard this 'induce', but I don't know what it means. I don't understand exactly," he said. His wife suffered a catastrophic bleed which doctors were unable to stem and she died after giving birth to her daughter at Gloucestershire Royal Hospital in March 2021. He said better interpreting services would have helped him and his wife understand what was happening. "It would have helped me and her to take the right decision for how she's going to deliver the baby and she can know what is going to happen to her," he added. The Healthcare Safety Investigation Branch (HSIB) found there were delays in calling for specialist help, there was no effective communication with Ms Abdelkarim, and the incident had traumatised staff. Gloucestershire Royal Hospitals NHS Foundation Trust has apologised and said it had acted on the coroner's recommendations to ensure lessons have been learned to prevent similar tragedies. Read full story Source: BBC News, 21 November 2023
  21. News Article
    Patient safety is being put at risk by the “toxic” behaviour of doctors in the NHS, the health ombudsman has said. Rob Behrens, who investigates complaints about the NHS in England, warned that the hierarchical and high-handed attitude of clinicians was undermining the quality of care in some hospitals. He called for medical training to be redesigned to encourage a more empathetic and collaborative approach from doctors. Pointing to failings in the treatment of sepsis and the problems in maternity services, Behrens said he was “shocked on a daily basis” by what he saw as ombudsman. Too often, “organisational reputation has been put above patient safety”, he told The Times Health Commission. The ombudsman warned of a “Balkanisation” of health professionals, with rivalries between doctors and nurses or midwives and obstetricians harming patient care. “For all the brilliance of clinicians quite often they’re not very good at working together,” he said. “Time and again, the handover from one clinician to another, from one shift to another, or the inability to raise the issue at a senior level has been a key factor in what has gone wrong.” Read full story (paywalled) Source: The Times, 18 November 2023
  22. News Article
    England's healthcare regulator has told BBC News that maternity units currently have the poorest safety ratings of any hospital service it inspects. BBC analysis of Care Quality Commission (CQC) records showed it deemed two-thirds (67%) of them not to be safe enough, up from 55% last autumn. The "deterioration" follows efforts to improve NHS maternity care, and is blamed partly on a midwife shortage. The Department for Heath and Social Care (DHSC) said £165m a year was being invested in boosting the maternity workforce, but said "we know there is more to do". The BBC's analysis also revealed the proportion of maternity units with the poorest safety ranking of "inadequate" - meaning that there is a high risk of avoidable harm to mother or baby - has more than doubled from 7% to 15% since September 2022. The CQC, which also inspects core services such as emergency care and critical care, said the situation was "unacceptable" and "disappointing". "We've seen this deterioration, and action needs to happen now, so that women can have the assurance they need that they're going to get that high-quality care in any maternity setting across England," said Kate Terroni, the CQC's deputy chief executive. The regulator has been conducting focused inspections because of concerns about maternity care. These findings are "the poorest they have been" since it started recording the data in this way in 2018, Ms Terroni said. Read full story Source: BBC News, 16 November 2023
  23. News Article
    Large numbers of midwives report being left feeling undervalued and afraid to speak up due to bullying and widespread staffing shortages, which some say is putting mothers’ and babies’ lives at risk, according to a new publication shared with HSJ. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. The report said: “Midwives have described their experiences of toxic cultures within their workplaces, with cliques, preferential treatment, unfounded allegations and poor working conditions leading to a negative impact on their health and wellbeing, including suicide attempts and midwives leaving their job or profession. Read full story Source: HSJ, 13 November 2023 Order a copy of the report
  24. Content Article
    *Trigger warning: This report contains accounts of bullying behaviours and consequences and may trigger those who have experiences of bullying. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. In the numerous accounts shared all areas of the system from CQC, CEO, HR, midwifery management, universities and the unions are described as being complicit, inadequate, disinterested and even corrupt. Accounts also refer to: Unsafe work environments Exit interviews not being performed, recorded or acted upon Staff not being valued Whistle-blowers being demonised until they leave Health and safety issues and truly evidence-based practice ignored with no lessons learned. To order your copy, follow the link below.
  25. News Article
    Black babies in England are almost three times more likely to die than white babies after death rates surged in the last year, according to figures that have led to warnings that racism, poverty and pressure on the NHS must be tackled to prevent future fatalities. The death rate for white infants has stayed steady at about three per 1,000 live births since 2020, but for black and black British babies it has risen from just under six to almost nine per 1,000, according to figures from the National Child Mortality Database, which gathers standardised data on the circumstances of children’s deaths. Infant death rates in the poorest neighbourhood rose to double those in the richest areas, where death rates fell. The mortality for Asian and Asian British babies also rose, by 17%. The annual data shows overall child mortality increased again between 2022 and 2023, with widening inequalities between rich and poor areas and white and black communities. Most deaths of infants under one year of age were due to premature births. Karen Luyt, the programme lead for the database and a professor of neonatal medicine at Bristol University, said many black and minority ethnic women were not registering their pregnancies early enough and the “system needs to reach them in a better way”. “There’s an element of racism and there’s a language barrier,” Luyt said. “Minority women often do not feel welcome. There’s cultural incompetence and our clinical teams do not have the skills to understand different cultures.” Read full story Source: The Guardian, 9 November 2023
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