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Showing results for tags 'Maternity'.
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News Article
Inadequate maternity unit handed safety warning
Patient Safety Learning posted a news article in News
An NHS maternity department has been handed a warning notice by the health regulator because of safety failings. The Care Quality Commission (CQC) said it was taking the action over the James Paget Hospital in Norfolk to prevent patients coming to harm. Inspectors found the unit did not have enough staff to care for women and babies and keep them safe. The maternity department has been deemed "inadequate" by the CQC, which meant the overall rating for the hospital has now dropped from "good" to "requires improvement". Between June and November 2022 there were 30 maternity "red flags" that the inspectors found, of which more than half related to delays or cancellations to time-critical activity. In one instance, there was a delay in recognising a serious health problem and taking the appropriate action. The report also highlighted the service did not have enough maternity staff with the right qualifications, skills, training and experience "to keep women safe from avoidable harm and to provide the right care and treatment". Read full story Source: BBC News, 31 May 2023 -
News ArticleThe Royal College of Midwives says the need for a maternity strategy in Northern Ireland has gone beyond urgent and is now critical. The warning comes as the RCM is publishing a report on Northern Ireland's maternity services at Stormont on Tuesday. The report will highlight growing challenges as more women across the country with additional health needs are being cared for by maternity services. The RCM report will outline three steps to deliver high quality and safe services for women and families. Develop, publish and fund the implementation of a new maternity and neonatal strategy for Northern Ireland. Sustain the number of places for new student midwives at their recent, higher level. Focus on retaining the midwives in the HSC. Read full story Source: ITV News, 30 May 2023
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Content ArticleIn March 2019, NHS England published Saving Babies Lives version 2, which included information for providers and commissioners of maternity care on how to reduce perinatal mortality across England. One element of this recommends the appointment of a fetal monitoring lead with the responsibility of improving the standard of fetal monitoring. The aim of the fetal monitoring lead is to support staff working on the labour ward to provide high quality intrapartum risk assessments and accurate CTG interpretation and should contribute to building and sustaining a safety culture on the labour ward with all staff committed to continuous improvement. The importance of fetal monitoring was highlighted again in the Ockenden Report, published December 2020. The report recommended, as an essential action, that all maternity services must appoint a dedicated lead midwife and lead obstetrician, both with demonstrated expertise, to focus on and champion best practice in fetal monitoring. Monitoring May is a month long learning event based around fetal monitoring, human factors, maternity safety and shared learning. The East Midlands Academic Health Sciences Network has shared the recording of Monitoring May’s discussions and presentations.
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News Article
East Kent: A decade of failure in maternity care
Patient Safety Learning posted a news article in News
After health inspectors considered closing a maternity unit over safety fears, the BBC's Michael Buchanan looks at a near-decade of poor care at East Kent Hospitals NHS Trust. "I've been telling you for months. The place is getting worse." The message in February, which Michael received from a member of the maternity team, was stark but unsurprising. In a series of texts over the previous few months, the person had been getting increasingly concerned about what was happening at the East Kent trust. The leadership is "totally ineffective" read one message. "How long do we have to keep hearing this narrative - we accept bad things happened, we have learned and are putting it right. Nothing changes." Friday's report from the Care Quality Commission (CQC) is unfortunately just the latest marker in a near-decade of failure to improve maternity care at the trust. The revelation that inspectors considered closing the unit at the William Harvey Hospital in Ashford comes nine years after the trust's head of midwifery made a similar recommendation for the same reasons - that it was a danger to women and babies. The failure to act decisively then allowed many poor practices to continue. Read full story Source: BBC News, 28 May 2023 -
News Article
Closing baby unit considered over safety concerns
Patient Safety Learning posted a news article in News
Health inspectors considered shutting down a maternity unit earlier this year over safety concerns. The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent. Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust. The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place. Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected. Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down." She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked. "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right. "The problems that are revealed are so fundamental that we have to do things differently." Read full story Source: BBC News, 26 May 2023 -
News ArticlePregnant women and new mothers are facing wide variation in access to mental health support, new figures suggest, as NHS England admits national performance on a key long-term plan goal to expand services is ‘over a year behind trajectory’. Analysis of access rates for perinatal mental health services from NHS Digital shows the rates of women accessing support within the past 12 months range from 3.7 per cent in Humber and North Yorkshire to 15 per cent in Shropshire, Telford and Wrekin ICS. The long-term plan target is for 66,000 women per year to be accessing specialist perinatal services, which can help with conditions such as post-partum psychosis, by March 2024. NHSE admitted in its papers that “although access is increasing, performance remains over a year behind trajectory”. Read full story (paywalled) Source: HSJ, 25 May 2023
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Content ArticleIn this blog Paul Whiteing, Chief Executive of AvMA, reflects on the recent report by the House of Commons Women and Equalities Committee on Black maternal health. Paul questions why these racial health disparities, that have long been reported on, have been allowed to continue over many decades and highlights the need for more challenging conversations as to wider root causes.
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News Article
Gloucestershire maternity units still shut after staff shortages
Patient Safety Learning posted a news article in News
Maternity services in Gloucestershire will remain shut for months because of staff shortages, it has been confirmed. The Aveta Birth Unit in Cheltenham and Stroud's post-natal facilities are not expected to re-open until at least October, bosses say. The announcement by Gloucestershire Hospitals NHS Foundation Trust means women will have been unable to use the services for more than a year. Maternity campaigners say new mothers are not getting support they need. The trust said it had a long-term commitment to both units, but they cannot reopen safely at the moment. The Aveta unit has been shut since last June and Stroud's six postnatal beds have been closed since September. It means new mothers are forced to go home 12 hours after giving birth, or if they have medical needs being sent to Gloucestershire Royal Hospital. Read full story Source: BBC News, 19 May 2023 -
Content ArticleRecently, there has been a concerning increase in the number of deaths of pregnant women, especially from Black, Asian and deprived backgrounds. In addition, there have been several investigations into safety issues in maternity services, such as the Ockenden, East Kent, and Shrewsbury and Telford report. This National Institute for Health and Care Research (NIHR) Collection highlights evidence in priority areas, identified in the East Kent report, to support high-quality care and avoid safety issues in maternity services.
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News ArticleAn inquiry into maternity care failings at an NHS trust that left dozens of babies dead or brain-damaged is “wholly insufficient” because only a fraction of Black and Asian women have come forward, its chair has warned. Donna Ockenden, who is leading a review into Nottingham University Hospitals NHS Trust, suggested the health service must do more to increase the number of responses from ethnic minorities if the trust is to learn from the scandal. Less than 20 families from Black and Asian communities are currently involved in the inquiry, compared to more than 250 white families, The Independent understands. It is understood letters have only been sent out in English, while Ms Ockenden pointed to examples of women being unable to access translation services and expectant Muslim mothers being turned away if they objected to male sonographers. She said the communities’ “mistrust” towards the trust had “deepened”, leaving the review team “climbing a mountain” to engage with them. Read full story Source: The Independent, 18 May 2023
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Content ArticleHealthcare systems rely on self-advocacy from service users to maintain the safety and quality of care. Systemic bias, service pressures and workforce issues often deny agency to patients at times when they need to have most control over representation of their story. This drives diagnostic error, treatment delay or failure to treat important conditions. In maternal care, perinatal mental health and thrombosis are significant challenges. With funding from SBRI Health care, Ulster University and Southern Health and Social Care Trust are developing an NLP powered platform that will empower mothers to be more active agents in their perinatal care. Download the poster below.
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News Article
Allegations of bullying within maternity programme of HSIB
Patient Safety Learning posted a news article in News
It was created with the very best of intentions – to help hospitals learn lessons when a baby or mother is harmed or dies. But a Channel 4 News investigation has been hearing that the maternity programme of the Healthcare Safety Investigation Branch – or HSIB – was riddled with flaws. One former senior staff member spoke to Channel 4 about bullying within the organisation and failings which could have led to harm. In a previous report, Channel 4 heard from the mothers of Beatrice and Marnie, who were stillborn and other parents have come forward with their experience. Watch the story Source: Channel 4 News, 16 May 2023 -
News Article
Babies are dying because of NHS failings, poverty and inequality, charities warn
Patient Safety Learning posted a news article in News
Hundreds of babies are dying unnecessarily because overstretched maternity services are delivering substandard care and struggling to overcome entrenched poverty and racial inequalities, a report has warned. The report by baby loss charities Sands and Tommy’s says the government’s aim to halve the number of stillbirths and neonatal deaths in England by 2025 is stalling, while there is no target in Scotland, Wales or Northern Ireland. Stillbirths are creeping up in England after falling in the past decade. Babies dying before and during delivery rose to just over four in every 1,000 births in 2021. Similarly, long-falling rates of neonatal deaths, where newborns die within the first four weeks of birth, are also rising. There were 1.4 deaths of newborn babies for every 1,000 births in 2021, compared with 1.3 in 2020. Robert Wilson, head of the charities’ joint policy unit, said the government and NHS need to make fundamental changes. “The UK is not making enough progress to reduce rates of pregnancy loss and baby death, and there are worrying signs that these rates are now heading in the wrong direction,” he said. Read full story Source: The Guardian, 14 May 2023 -
Content ArticleIn 2022 the charities Sands and Tommy’s came together to form a Joint Policy Unit. Together they are focussed on achieving policy change that will save more babies’ lives during pregnancy and the neonatal period and on tackling inequalities in loss, so that everyone can benefit from the best possible outcomes. This first report from the Unit brings together a range of evidence to identify the key changes needed to save more babies’ lives and reduce inequalities in pregnancy and baby loss. None of the individual data it contains is new, but it gives decision makers a clear view of where we are now, and where action is required to make progress.
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News ArticleThe death rates for black women in childbirth were revealed in a recent report from MPs and were described as “appalling”, yet action, not words, are needed for what could be considered breaches of the Human Rights Act. Ministers are not giving priority to reducing the gap in health inequalities, write Nicola Wainwright and Suleikha Ali in a commentary to the Times. "If the response to the review is foot-dragging from the government and senior health service officials, then legal action may be the only way to draw focus to this issue and to try to reduce the number of ethnic minority women and babies dying unnecessarily." The report, published by the women and equalities committee last month, highlights the “glaring and persistent” disparities faced by ethnic minority women compared to their white counterparts with regards to pregnancy and birth. However, these same disparities have been known and reported on for 20 years, while progress on improving the situation has been shockingly slow. Read full story (paywalled) Source: The Times, 11 May 2023
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News Article
Simple intervention for severe blood loss after childbirth is found to save lives
Patient Safety Learning posted a news article in News
A simple intervention to detect and treat postpartum haemorrhage could dramatically cut maternal mortality and morbidity worldwide, a large trial led by the University of Birmingham has shown. Use of a special drape to measure blood loss during childbirth and rapid deployment of a “bundle” of existing treatments reduced severe bleeding, the need for laparotomy, or maternal death by 60% in a study done in 80 hospitals across Kenya, Nigeria, South Africa, and Tanzania. Reporting the results in the New England Journal of Medicine, the researchers said that postpartum haemorrhage was detected in 93.1% of patients in the intervention and in 51.1% of those receiving usual care. Read full story (paywalled) Source: BMJ, 10 May 2023 -
News Article
Figures show maternal death rate race disparity
Patient Safety Learning posted a news article in News
Figures showing the risk of maternal death being almost four times higher among women from black ethnic minority backgrounds compared with white women in the UK have been published. The figures, which relate to 2019 - 2021, have been released by MBRRACE-UK, a collaboration involving the University of Leicester. The MBRRACE-UK collaboration (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries), led from Oxford Population Health's National Perinatal Epidemiology Unit, looked at data on women who died during, or up to six weeks after, pregnancy between 2019 and 2021 in the UK. The report showed the risk of maternal death in 2019 - 2021 was almost four times higher among women from black ethnic minority backgrounds compared with white women. Marian Knight, professor of Maternal and Child Population Health at Oxford Population Health and maternal reporting lead, said: "Persistent disparities in maternal health remain. "It is critical that we are working towards more inclusive care where women are listened to, their voices are heard, and we are acting upon what they are telling us." Read full story Source: BBC News, 11 May 2023 -
EventuntilLearn from Dr Bill Kirkup and other key speakers about recent National Maternity Service Reviews and how they are changing practice. Register
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News ArticleMaternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
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News Article
Failure to recognise ectopic pregnancy causing women’s deaths, says expert
Patient Safety Learning posted a news article in News
Women are dying or suffering avoidable harm because of a failure to recognise ectopic pregnancy, one of the country’s leading experts on maternal health has said. Speaking to the Guardian, Prof Marian Knight of the University of Oxford, who leads a national research programme on maternal deaths, called for action to improve diagnosis of the acute, life-threatening condition, in which a fertilised egg implants itself outside the womb, normally in the fallopian tube. Ectopic pregnancies are never viable and if left untreated can result in the tube rupturing, causing potentially fatal internal bleeding. “We could prevent more women from dying from ectopic pregnancy because of lacking of basic recognition and management of the condition,” said Knight. The warning comes as new data obtained by freedom of information request suggests that dozens of women have experienced “severe harm” after being admitted to hospital with ectopic pregnancies in the past five years. The Mbrrace report, published last year, said eight women died from ectopic pregnancies between 2018 and 2020, all but one of whom had received suboptimal treatment. In three instances, better care might have saved their lives, the report concluded. “There’s no doubt that in the [maternal deaths] inquiry we are still seeing the same messages of ectopic pregnancy not being recognised,” said Knight. “That people either don’t pick up on the fact that they’re pregnant or get single-minded about one diagnosis.” Read full story Source: The Guardian, 1 May 2023 -
Content Article
Black and Asian bereaved parents whose baby died during pregnancy or shortly after birth have shared their experiences as part of the Sands Listening Project. The 56 parents who took part shone a light on care that works well, while also highlighting barriers, biases, and poor care. In the report, published by Sands, you can read more about: the findings pregnancy loss and baby deaths among Black and Asian babies in the UK real-life experiences and case studies what needs to change. Follow the link below to access the Listening Project report on the Sands website. -
News Article
Hospital to send hundreds of births elsewhere
Patient Safety Learning posted a news article in News
The trust at the centre of a maternity scandal is trying to reduce the number of births at its main maternity units by 650 a year following a highly critical Care Quality Commission (CQC) visit. East Kent Hospitals University Foundation Trust is looking at ways to reduce pressure on staff at the William Harvey Hospital in Ashford, including stopping bookings from women who are “out of area”. The unit currently has around 3,600 births a year, of which 200 are out-of-area bookings. The trust is also seeking to send more births to its other site, in Thanet. It comes after the CQC used enforcement powers to order immediate improvements at the unit, following a visit in January, when it had “significant concerns about the ongoing wider risk of harm to patients”. Earlier this year, the trust’s new chief executive, Tracey Fletcher, held what board papers describe as an “emotional” meeting with 135 midwives, other staff and senior Royal College of Midwives representatives. She was told by staff that the service at the WHH was not felt to be safe due to a lack of substantive staff, high acuity of patients and the level of activity. Read full story (paywalled) Source: HSJ, 28 April 2023 -
News Article
Alternative to epidural recommended for women in labour
Patient Safety Learning posted a news article in News
Women in labour should be offered an alternative to an epidural spinal block injection, say new draft guidelines for the NHS. The National Institute for Health and Care Excellence (NICE) is recommending remifentanil, which is a fast-acting morphine-like drug given into a vein. Women control the medication themselves, by pressing a button to get more of the drug for pain relief. A timer ensures the user cannot administer too much of it. Women who decide to try remifentanil and do not like it could still decide to have an epidural instead if there is no medical reason why they should not. They can use gas and air, also called Entonox, which is a mix of oxygen and nitrous oxide, at the same time. NICE says having remifentanil as a treatment option has advantages - it might enable women to be more mobile than with an epidural, which makes the legs numb and weak, for example. Evidence suggests fewer epidurals might mean fewer births using instruments like forceps and ventouse vacuum suction, says NICE. Read full story Source: BBC News, 25 April 2023 -
News Article
Cover-ups and lies in maternity care keep happening, says Donna Ockenden
Patient Safety Learning posted a news article in News
A week after Donna Ockenden published her damning report on the catastrophic failures in maternity services at Shrewsbury and Telford Hospital NHS Trust in March last year, she was contacted by families in Nottingham asking her to investigate how dozens of babies had died or been injured in their city hospitals. Six months later, Ockenden — herself a senior midwife — was put in charge of another inquiry by the government and yet again she is finding a culture of cover-ups and lies in maternity care. “Of the families that I have met in Nottingham to date, some of them have expressed concerns to me that the trust were not truthful in discussions around their cases,” she tells the Times Health Commission. “We have all the systems and structures in place that should be able to spot maternity services in difficulty and here we are again. Families are having to fight to get answers.” The woman who has done more than anyone to highlight the problems with maternity care is reluctant to use the word “crisis” but she warns: “I think that without urgent and rapid action, from central government downwards — on funding and workforce and training — mothers and their babies are not going to be able to receive the safe, personalised maternity care that they deserve and should expect". Read full story (paywalled) Source: The Times, 21 April 2023 -
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)
