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Content Article
This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. -
News ArticleThe trust at the centre of a maternity scandal insists it has been providing immediate anaesthetic cover for obstetric emergencies, contrary to an NHS England report suggesting it had not and had been potentially breaching safety standards. Health Education England – now part of NHSE – visited William Harvey Hospital in March and was told senior doctors in training who were covering obstetrics could also be covering the cath lab – which deals with patients who have had a heart attack, and could receive trauma, paediatric emergency and cardiac arrest calls. This suggested the trust was in conflict with Royal College guidelines which state an anaesthetist should always be “immediately available” for obstetrics. East Kent Hospitals University Foundation Trust, which runs the hospital, originally told HSJ its rota had very recently been changed and that an anaesthetist with primary responsibility for maternity could leave any other work to attend to a maternity emergency immediately. However, it has since said it has been the case for a long time that an anaesthetist is available to return to maternity in case of an emergency. Read full story (paywalled) Source: HSJ, 17 June 2023
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News ArticleSoon after her son Jaxson was born, Lauren Clarke spotted that his eyes were yellow and bloodshot. “We kept asking if he had jaundice, but each time we were told to keep feeding him and just put Jaxson in front of a window,” she says. It was only when Clarke was readmitted six days later with an infection that Jaxson’s jaundice was detected by a midwife. By this time, his levels were becoming dangerously high. “We spent a further five days in hospital for Jaxson to be treated with light therapy and antibiotics. If I hadn’t had to go back to hospital, he could have died or had serious long-term health conditions,” she says. This week, the NHS race and health observatory will announce new funding for research into the efficacy of jaundice screening in black, Asian and minority ethnic newborns on the back of a recent report showing that tests to assess newborn babies’ health are not effective for non-white children. The research cannot come too soon. Jaxson’s aunt, Gemma Poole, a midwife from Nottingham, created her company, the Essential Baby Company, to develop resources and training about the specific needs of women and babies with black and brown skins, after Jaxson’s jaundice was initially missed by clinicians. Poole believes the trauma her nephew, brother and sister-in-law had to go through could have been avoided if health professionals had known better ways to spot jaundice in non-white babies. “The colour of gums, the soles of the feet and hands, the whites of eyes, how many wet and dirty nappies and if the baby is waking for feeds and alert could be more reliable indicators if a black or brown baby has jaundice,” she says. Read full story Source: The Guardian, 16 July 2023
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News Article
Maternity unit breached safety standards
Patient Safety Learning posted a news article in News
A trust at the centre of a maternity scandal has been failing to meet Royal College standards in one of its maternity units, HSJ can reveal. The duty anaesthetist for the maternity unit at the William Harvey Hospital in Ashford has also had to cover the hospital’s primary percutaneous coronary intervention suite. This could mean no anaesthetist is available to carry out an emergency Caesarean if they are needed to treat a heart attack patient. This goes against Royal College of Anaesthetists’ guidelines, which say a duty anaesthetist must be “immediately available for the obstetric unit 24/7”. The guidelines add that where the duty anaesthetist has other responsibilities – because, for example, they work at a smaller maternity unit where the workload does not justify them being there exclusively – then “these should be of a nature that would allow the activity to be immediately delayed or interrupted should obstetric work arise”. The William Harvey unit is East Kent Hospitals University Foundation Trust’s major birth centre. The trust has around 6,500 births a year – the majority at the WHH – and was heavily criticised for poor maternity care in a report by Bill Kirkup last year. Read full story Source: HSJ. 17 July 2023 -
News Article
Black maternal health in crisis across hemisphere, not just in USA
Patient Safety Learning posted a news article in News
Black women in the Americas bear a heavier burden of maternal mortality than their peers, but according to a report released Wednesday by the United Nations, the gap between who lives and who dies is especially wide in the world’s richest nation — the United States. Of the region’s 35 countries, only four publish comparable maternal mortality data by race, according to the report, which analyzed the maternal health of women and girls of African descent in the Americas: Brazil, Colombia, Suriname and the United States. And while the United States had the lowest overall maternal mortality rate among those four nations, the report said Black women and girls were three times more likely than their U.S. peers to die while giving birth or in the six weeks afterward. “The risk factor is racism,” said Joia Crear-Perry, an OB/GYN and founder of the National Birth Equity Collaborative, a nonprofit group dedicated to eliminating racial inequities in birth outcomes and one of the report’s co-sponsors. “This report drives this home over and over. When your pain is ignored, when your blood pressure is ignored, you die, and that happens across the Americas.” Read full story (paywalled) Source: The Washington Post, 12 July 2023 -
Content ArticleTests that indicate the health of newborns, moments after birth, are limited and not fit-for-purpose for Black, Asian and ethnic minority babies, and need immediate revision according to the NHS Race and Health Observatory.
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News Article
Baby died of brain injury after midwives ‘neglected’ mum while breastfeeding
Patient Safety Learning posted a news article in News
Olly Vickers died of a brain injury in February last year just weeks after two midwives at Royal Bolton Hospital let his mother Emma Clark feed him while she was having gas and air – in breach of guidelines. Despite being well when he was born, Olly was found “pale and floppy” hours later due to his airways being obstructed. He developed a brain injury and died five months later. Coroner Peter Sigee ruled his death was a result of “neglect” and due to a “gross failure to provide basic medical care”. An inquest into his death heard a student midwife placed a pillow under his mother’s arm while she was feeding him, “contrary to accepted practice”. Another midwife then gave Ms Clark gas and air while she was feeding Olly as she was stitched up for a tear obtained during labour – which again went against guidance. No risk assessment was carried out and the coroner said Olly’s breastfeeding should have been stopped before the midwives began to suture Ms Clark. Read full story Source: The Independent, 8 July 2023 -
News Article
Nottingham maternity review set to become UK's largest
Patient Safety Learning posted a news article in News
A review into failings in maternity care in hospitals in Nottingham is set to become the largest in the UK, the BBC understands. Donna Ockenden, chair of the inquiry, is expected to announce that 1,700 families' cases will be examined. She was in charge of the probe into services in Shropshire, which found at least 201 babies and mothers might have survived had they received better care. The review comes after dozens of baby deaths and injuries in Nottingham and focuses on the maternity units at the Queen's Medical Centre and City Hospital. So far, 1,266 families have contacted the review team themselves directly and to date, 674 of these have given consent to join it. But Ms Ockenden has called for a "radical review" to ensure "women from all communities" were being contacted by the trust and "felt confident" to come forward. Read full story Source: BBC News, 10 July 2023 -
Content ArticleNHS Resolution has launched its first eLearning module that focuses on learning from the significant avoidable harm that can occur during antenatal and postnatal care and is seen in the cases notified to its Early Notification Scheme. This free resource is designed to support clinicians working in maternity services. The module uses three illustrative case stories to immerse learners into the antenatal, intrapartum and postnatal care provided to mothers and the neonatal care provided to their babies. It aims to deepen learners' understanding of NHS Resolution’s role within the healthcare system, develop their understanding of the law of negligence as applied to clinical claims and explore how clinical decisions and actions can lead to avoidable harm. The module takes approximately two-and-a-half hours to complete and can be used as evidence of CPD hours undertaken for revalidation.
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News ArticleNearly half of all NHS hospital maternity services covered so far by a national inspection programme have been rated as substandard, the Observer can reveal. The Care Quality Commission (CQC), which regulates health and care providers in England, began its maternity inspection programme last August after the Ockenden review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by inadequate NHS care. Of the services inspected under the programme, which focuses on safety and leadership, about two-thirds have been found to have insufficient staffing, including some services that were rated as good overall. Eleven services saw their rating fall from their previous inspection. Dr Suzanne Tyler of the Royal College of Midwives said: “Report after report has made a direct connection between staffing levels and safety, yet the midwife shortage is worsening. Midwives are desperately trying to plug the gaps – in England alone we estimate that midwives work around 100,000 extra unpaid hours a week to keep maternity services safe. This is clearly unsustainable and now is the time for the chancellor to put his hand in the Treasury pocket and give maternity services the funding that is so desperately needed.” Read full story Source: The Guardian, 9 July 2023
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News Article
US maternal deaths doubled in last 20 years, study finds
Patient Safety Learning posted a news article in News
Maternal mortality rates have doubled in the US over the last two decades - with deaths highest among black mothers, a new study suggests. American Indian and Alaska Native women saw the greatest increase, the study in Journal of the American Medical Association (JAMA) said. Southern states had the highest maternal death rates across all race and ethnicity groups, the study found. In 1999, there were an estimated 12.7 deaths per 100,000 live births and in 2019 that figure rose to 32.2 deaths per 100,000 live births in 2019, according to the research, which did not study data from the pandemic years. Unlike other studies, this one examined disparities within states instead of measuring rates at the national level, and it monitored five racial and ethnic groups. Dr Allison Bryant, one of the study's authors, said the findings were a call to action "to understand that some of it is about health care and access to health care, but a lot of it is about structural racism". She said some current policies and procedures "may keep people from being healthy". Read full story Source: BBC News, 4 July 2023 -
Content ArticleEvidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. The objective of this study was to quantify trends in MMRs (maternal deaths per 100 000 live births) by state for five mutually exclusive racial and ethnic groups using a bayesian extension of the generalised linear model network. The study found that while maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.
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Content ArticleSince retiring from his role in public health, Dr Bill Kirkup has focused on independent investigations into public service failures, including maternity services at Morecambe Bay and East Kent. In this podcast, Bill talks to Parliamentary and Health Service Ombudsman Rob Behrens about his career, what he's learnt during his investigations and how we can make more progress in improving patient safety.
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News Article
Ministers refuse to set target for ending maternal deaths disparity
Patient Safety Learning posted a news article in News
The government has rejected calls to set a target and strategy to end ‘appalling’ disparities in maternal deaths. In response to a Commons women and equalities committee report, published on Friday, ministers said a “concrete target does not necessarily focus resource and attention through the best mechanisms”. The response added: “We do not believe a target and strategy is the best approach towards progress.” The government said disparities will be monitored through local maternity and neonatal systems, which are partnerships comprising commissioners, providers and local authorities. A recommendation to increase the annual budget for maternity services to up to £350m per year, backed by the now chancellor Jeremy Hunt, and maternity investigator Donna Ockenden, was also rejected. Read full story Source: HSJ, 3 July 2023 -
News Article
Sight-saving drug to be offered to premature babies, announces NHS
Patient Safety Learning posted a news article in News
Premature babies across England will be offered a sight-saving drug, the NHS has announced. Retinopathy of prematurity (ROP) is an eye disease that can occur among babies who are born early or those born with a low birth weight. The NHS routinely screens these babies for the condition, which affects blood vessels in the retina, creating damaging scar tissue and causing blindness. Traditionally the condition is treated with laser eye surgery but some babies are too unwell or fragile to have the treatment. Now the NHS is offering new “life-changing” drug ranibizumab to babies with ROP across England who are unable to receive traditional treatment. NHS chief executive Amanda Pritchard said: “The impacts of vision loss can be absolutely devastating, particularly for children and young people, so it’s fantastic that this treatment will now give families across the country another life-changing option to help save their child’s precious sight." Read full story Source: The Independent, 4 July 2023 -
Content ArticleOn the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report.
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Content ArticlePostpartum hypertensive disorders pose a serious health risk to new mothers; nearly 75 percent of maternal deaths associated with hypertensive disorders occur in the postpartum period. For the past decade, the obstetrics department at the Hospital of the University of Pennsylvania (HUP) has tried to lower these risks by checking patients’ blood pressure after they are released from the hospital. Their initial efforts to have patients return to the office for an in-person blood pressure check shortly after discharge yielded disappointing results, so the team revamped their approach and ultimately developed an extremely successful program called Heart Safe Motherhood. The programme started when the team at HUP gave a small group of women a blood pressure cuff each. They told them they would receive text messages after discharge instructing them to take their blood pressure at 8am, and that they would need to send in the reading. At 1pm, they would get another text requesting that they send their blood pressure again. This article describes how Heart Safe Motherhood evolved to improve the likelihood of mothers submitting their readings, and how the programme was scaled up to five hospitals in the group. It looks at how the approach has helped tackled health inequalities and improved the safety of postpartum mothers.
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News ArticleShrewsbury and Telford Hospital Trust temporarily suspended admissions to the women’s and children’s centre at Princess Royal Hospital – which houses the provider’s consultant-led maternity services – earlier this week due to an issue with a generator. HSJ understands a power cut occurred and estates chiefs were concerned about running solely on battery power, hence suspending admissions while the problem was fixed. Five inductions of labour were diverted to neighbouring trusts, while fewer than five caesarean sections were rescheduled during the outage. Meanwhile, 56 patients accessing the trust’s telephone triage service were advised by medical chiefs to attend nearby hospitals. Following the incident, a learning review is taking place, and HSJ understands this will investigate whether any women came to harm. HSJ has also been told the generator has been fixed “as good as permanently”. Read full story (paywalled) Source: HSJ, 23 June 2023
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EventuntilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. This workshop will cover key information and questions regarding the transition to PSIRF within maternity settings. Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Lauren Mosley, Head of Patient Safety Implementation, NHS England, TBC Register
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Content Article
In 2022, an illustration of a Black foetus in the womb by Nigerian medical illustrator and medical student Chidiebere Ibe, went viral. The image sparked an important conversation around representation in medical imagery and the impact this has on health outcomes for patients who are Black, Indigenous and people of colour (BIPOC). Research showed that only 5% of medical images show dark skin and only 8% of medical illustrators identified as BIPOC. A collaboration between Chidiebere Ibe, Deloitte and Johnson & Johnson, Illustrate Change aims to build the world's largest library of BIPOC medical illustrations for use in medical education and training. So far, the library contains images relevant to the following specialties: Dermatology Eye disease General health Haematology Maternal health Oncology Orthopaedics -
Content ArticleRace and ethnicity have been associated with poor pregnancy outcomes in many countries. In the UK, the rates of baby death and stillbirth among Black and Asian mothers are double those for White women. Most studies examine trends for individual countries. This large database study explored how race and ethnicity is linked to pregnancy outcomes in wealthy countries. Key findings Black women consistently had worse outcomes than White women across the globe. Hispanic women were three times more likely to experience baby death compared with White women. South Asian women had an increased risk of early birth and having a baby with an unexpectedly low weight (small for the length of pregnancy) compared with White women. Racial disparities in some outcomes were found in all regions. The researchers call for a global, joined-up approach to tackling disparities. Breaking down barriers to care for ethnic minorities, particularly Black women, could help. More research is needed to understand why outcomes are for worse for ethnic minorities. The researchers recommend routine collection of data on race and ethnicity. The link below takes you to the Plain English summary of the research, you can also view the full research study.
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News Article
Maternity failures behind most big NHS payouts
Patient Safety Learning posted a news article in News
More than three quarters of all multimillion-pound NHS medical negligence payouts are the consequences of failures in maternity care, new figures show. In total, 364 patients or families received the highest-value compensation payments of at least £3.5 million after suing the NHS last year. Of those, 279 (77%) were maternity-related damages, according to figures from NHS Resolution. The large payouts have been offered to parents whose babies were stillborn or suffered avoidable life-changing disabilities or brain injuries. Maternity makes up the bulk of NHS compensation payments. There were more than 10,000 clinical negligence claims brought against the NHS in 2021-22, with a total value of more than £6 billion. Maternity accounted for 62% of payments, or £3.74 billion. When taking into account all cost of harm, including future periodic payments and legal costs, the cost of compensating mothers and their families rises to £8.2 billion a year. Analysis by The Times Health Commission found that this is more than twice the £3 billion spent by the NHS annually on maternity and neonatal services. Maternity claims have increased during the past decade amid a string of high-profile scandals and a shortage of midwives. Read full story (paywalled) Source: The Times, 12 June 2023 -
Content ArticleAn NHS consultant who was sacked after whistleblowing says it was because he raised concerns that “normal birth” ideology was putting the lives of women and babies at risk. Martyn Pitman, a respected obstetrician and gynaecologist, became a whistleblower to prevent “avoidable disasters” in NHS maternity care, but it cost him his career. Pitman lost his job last month after more than 20 years as a consultant at Royal Hampshire County Hospital in Winchester. His bosses cited an “irretrievable breakdown in his relationship with management”. His dismissal caused outrage from hundreds of former patients and doctors’ leaders, who say it highlights an NHS culture of “punishing those who dare to speak out”.
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Content ArticleThis study in BMJ Open Quality aimed to assess the patient safety status in selected hospitals in Ghana. The authors concluded that the current patient safety status in the hospitals in the study was generally good, with the highest score in the knowledge and learning in the patient safety domain. Patient safety surveillance was identified as the weakest action area.
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Content Article
The National Institute for Health and Care Research (NIHR) Evidence Collections draw together evidence from important NIHR-funded and wider research. They aim to help people in policy and practice understand recent important research in a topic area. The most recent Collection is Maternity services: evidence for improvement. In this blog, one of the Collection's authors, Candace Imison, describes how it was framed by the findings from a recent investigation into failings in East Kent Hospitals’ maternity services. She focuses on some key messages from evidence on how to identify poor performance and provide effective board governance and oversight.
