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Found 816 results
  1. News Article
    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
  2. 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. 
  3. News Article
    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
  4. News Article
    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
  5. News Article
    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
  6. Content Article
    On 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)
  7. Event
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    The Black Maternal Health All Party Parliamentary Group (APPG) is having a meeting to discuss various updates and new improvements that have been made in the maternity world. The meeting will be hosted and chaired by Bell Ribeiro-Addy MP, Chair of the APPG and the Secretariat of the APPG is provided by Five X More CIC The E8 Group and Mimosa Midwives. The APPG aims to raise awareness of the issue of racial disparities within maternal healthcare and offer solutions to end this. Register
  8. News Article
    The mother of a young woman who died with herpes said she was "disgusted" with an NHS trust which "lied" about the potential cause of the virus. Kim Sampson and Samantha Mulcahy died with herpes after the same obstetrician at the East Kent Hospitals University NHS Trust carried out their caesareans. Yvette Sampson's daughter had been "fit and healthy" until she gave birth on 3 May 2018, an inquest has heard. She said the trust had lied about links between the two mothers' deaths. They were treated by the same surgeon and midwife six weeks apart, neither of whom were tested for herpes, the inquest in Maidstone was told. Ms Sampson said her daughter had been "in agony" from 3 May when she gave birth to her second child, until she died on 22 May. She told the inquest she had received "poor treatment" by midwives at the Queen Elizabeth the Queen Mother Hospital (QEQM) in Margate, which she felt also "contributed" to her daughter's death. Ms Sampson was initially denied a Caesarean and instead told to push for almost three hours, despite repeatedly telling midwives that "something wasn't right" and "clinging to the bed in agony", her mother said. Read full story Source: BBC News, 20 April 2023
  9. News Article
    The Women and Equalities Committee in a recent report has challenged the government over failures to address inequalities in maternity care which have led to Black women dying at four times the rate of white women. Tinuke Awe, 31, was left ‘traumatised’ and forced to go without pain relief after midwives didn’t believe she was in labour. Ms Awe, was induced after experiencing late pre-eclampsia while pregnant with her first child in 2017. She said: “Pre-eclampsia can be life-threatening for mum and baby, and it could’ve been fatal if I wasn’t treated. I was told I couldn’t leave the hospital and had to be induced". “They said the hormones could take 24 hours to work, but my labour happened really quickly and when I told the midwife she didn’t even believe I was in labour.” “I felt so overlooked and it was horrible how nobody listened to me,” she added. “I ended up having to have an assisted delivery which isn’t what I wanted, but it could’ve been avoided if someone had acknowledged I was in labour rather than ignore me. I just felt so unimportant.” Ms Aew alongside Clotilde Abe set up the charity Five X More. The organisation helps give advice and empower Black women to make informed choices during pregnancy and after childbirth. Five X More hope that the testimonials of the women they support can be used to show that better outcomes are possible with their ‘five steps for self-advocacy‘ being used to encourage women to ask for things like a second opinion. Read full story Source: The Independent, 18 April 2023 Read our interview with Tinuke Awe on the hub: Five X More campaign: Improving maternal mortality rates and health outcomes for black women
  10. News Article
    Anew model of care which the Public Health Agency (PHA) say will 'improve maternity services for women and babies in Northern Ireland' is being launched. The new model, which will see women receive support from the same midwifery team during pregnancy, birth and in the early days after birth, is being rolled out across all Health and Social Care (HSC) Trusts in the coming months. ‘Continuity of Midwifery Carer’ (CoMC) is a new model of care for women throughout their childbirth journey "that will provide positive clinical outcomes and higher care satisfaction", the PHA said. Chief Nursing Officer for Northern Ireland, Maria McIlgorm said: “This is a very positive development for maternity services in Northern Ireland. There is a clear evidence base behind the Continuity of Midwifery Carer model which shows that when a woman knows their midwife it can make a significant difference to their experience and outcome. “This woman and family-centred model of care will mean that women across Northern Ireland using our maternity services will receive support from the same dedicated midwifery team throughout their pregnancy, birth and postnatal period.” Read full story Source: Belfast Live, 12 April 2023
  11. News Article
    An MPs' report is calling for faster progress to tackle "appalling" higher death rates for black women and those from poorer areas in childbirth. The Women and Equalities Committee report says racism has played a key role in creating health disparities. But the many complex causes are "still not fully understood" and more funding and maternity staff are also needed. The NHS in England said it was committed to making maternity care safer for all women. The government said it had invested £165m in the maternity workforce and was promoting careers in midwifery, with an extra 3,650 training places a year. Black women are nearly four times more likely than white women to die within six weeks of giving birth, with Asian women 1.8 times more likely, according to UK figures for 2018-20. And women from the poorest areas of the country, where a higher proportion of babies belonging to ethnic minorities are born, the report says, are two and a half times more likely to die than those from the richest. Caroline Nokes, who chairs the committee, said births on the NHS "are among the safest in the world" but black women's raised risk was "shocking" and improvements in disparities between different groups were too slow. "It is frankly shameful that we have known about these disparities for at least 20 years - it cannot take another 20 to resolve," she added.
  12. Content Article
    In the UK, maternal mortality for Black women is currently almost four times higher than for White women, and significant disparities also exist for women of Asian and mixed ethnicity. In this report the Women’s and Equalities Select Committee reviews what is currently understood about the reasons for disparities in maternal deaths, analyses Government and NHS action to date and existing recommendations for change and consider the ongoing challenges to addressing disparities.
  13. Content Article
    A doula, according to Doula UK (2022), provides ‘support in pregnancy, birth and in the postnatal period by providing information, advocacy, and practical and emotional support to the whole family’. This blog by the Healthcare Safety Investigation Branch (HSIB) maternity team outlines why HSIB decided to investigate the role of doulas in maternity safety and the results of their investigation. It highlights discrepancies in doula training and several cases where doulas stepped outside of the boundaries of their role. HSIB argues that there is a need for further work to understand how families view the role of doulas during pregnancy and birth.
  14. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place
  15. Content Article
    This paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.
  16. News Article
    NHS trusts have been given until 2027-28 to employ enough midwives to meet safe staffing requirements, NHS England’s new maternity delivery plan has said. The three-year delivery plan for maternity and neonatal services sets out to “make maternity and neonatal care safer, more personalised and more equitable for women, babies and families”. It says: “Trusts will meet establishment [requirements] set by midwifery staffing tools and achieve fill rates by 2027-28, with new tools to guide safe staffing for other professions from 2023-24.” The plan follows a series of high-profile maternity scandals in the NHS at Shrewsbury and Telford, East Kent, Morecambe Bay and an ongoing independent review by Donna Ockenden into Nottingham University Hospitals Trust. The Care Quality Commission has highlighted a string of other concerns across the NHS. Read full story Source: HSJ, 31 March 2023
  17. Content Article
    This plan from NHS England sets out how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. NHS England has engaged a wide range of stakeholders who supported the development of this plan. This includes women and families who have used or are using maternity and neonatal services, members of the maternity and neonatal workforce, leaders and commissioners of services, NHS systems and regional teams, and representatives from Royal Colleges, charities and other organisations.
  18. Content Article
    Poster presentation from Dr Felicity Brokke and Ken Spearpoint at the recent GOSH Patient Safety and Human Factors Conference.
  19. News Article
    Mothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  20. Content Article
    Women should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
  21. Event
    Baby Lifeline has announced that their fourth annual National Maternity Safety Conference will take place on Thursday 21st September 2023 at the Hilton Metropole Hotel in Birmingham. Once again it will be focussing on learning together for a safer maternity future, building on the overwhelming success of the previous three conferences. Baby Lifeline is always keen to showcase best practice in healthcare and are pleased to welcome poster presentation abstracts again this year. They are particularly keen to hear about maternity service quality improvement measures which speak to one or more of the following themes: Listening to families and staff Promoting safety culture Teamworking Reducing mortality & morbidity. Register
  22. News Article
    Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023
  23. News Article
    Women at risk of dying in pregnancy or childbirth will be treated at a network of specialist NHS centres under a national drive to halve maternal deaths. For the first time, women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy. Two thirds of maternal deaths in the UK are due to medical conditions that pre-date or develop during pregnancy, rather than direct complications of birth. Previously there was no dedicated national service for these women. The 17 NHS centres, covering every region of the country, aim to prevent these deaths by bringing together specialist doctors, obstetricians, midwives and nurses under one roof. GPs and A&E staff will also be trained to identify “red flag” symptoms of illnesses in pregnant women and refer patients directly to the centres, where they can be assessed and receive medication or procedures. Read full story (paywalled) Source: The Times, 20 March 2023
  24. News Article
    Unconscious bias in the UK healthcare system is contributing to the stark racial disparity in maternal healthcare outcomes, a conference has heard. The Black Maternal Health Conference UK, also heard that black women not being listened to by healthcare professionals was also a contributing factor. The conference, organised by The Motherhood Group, was arranged to highlight the racial inequality in maternal healthcare and the disparity in maternal mortality between white, ethnic minority and black women in the UK. Black women in the UK are four times more likely to die in pregnancy and childbirth than white women, according to a report published by MBRRACE-UK. Asian women are twice as likely to die in pregnancy or childbirth. Sandra Igwe, who founded the NGO The Motherhood Group in 2016 after the traumatic birth of her daughter, told the PA Media that the event was an opportunity to “bridge the community, stakeholders, professionals, [and] government”, de-stigmatise mental health and bring about change to improve black maternal health. “There are so many stats – so why wouldn’t we have a whole day’s conference dedicated to addressing these, just scratching the surface of some of the stats?” Charities and activists have been raising alarm bells about the dangerous consequences of unconscious bias in maternal healthcare for many years. Igwe co-chaired the Birthrights inquiry, a year-long investigation into racial injustice in the UK maternity services, which heard testimony from women, birthing people, healthcare professionals and lawyers and concluded that “systemic racism exists in the UK and in public services”. Read full story Source: The Guardian, 20 March 2023 Sandra Igwe is our hub topic lead for Black Maternal Health. Read our recent interview with Sandra.
  25. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Isabela shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy. She talks to us about the vital role of patient campaigners in driving the movement to reduce avoidable harm, and why we need to shift from patient inclusion to belonging in order to improve patient safety.
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