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The report sets out seven themes identified by the review and charts the safety risks for pregnant women that emerged as the NHS adapted to respond to COVID-19. It describes the circumstances and pathways of care for the 19 women where some of the risks identified in the theme areas may have contributed to the outcome for those women. The review also highlighted that the ‘system factors’ identified in the maternal reviews were seen across the NHS and have been or are being addressed in other HSIB investigations. The seven themes are: Unprecedented demand for telephone health advice- Posted
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Staff at a Midlands hospital trust told regulators they had repeatedly raised safety concerns internally without action being taken. The Care Quality Commission (CQC) has downgraded maternity services at Worcestershire Acute Hospital from “good” to “requires improvement” following an inspection prompted by the whistleblowers’ concerns. Staff had reported “continuously escalating” staffing level concerns to senior managers, but said they got “no response”. Some said they were fearful of raising concerns internally. Whistleblowers also reported delays to induction of labour, with- Posted
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‘Legally wrong’ to make pregnant women with Covid give birth alone
Patient Safety Learning posted a news article in News
NHS guidance which often forces pregnant women who test positive with coronavirus to give birth alone is legally wrong, lawyers warned. Official guidance drawn up by NHS England states that if a woman tests positive for Covid, their husband or partner must self-isolate at home and is not allowed to support them during childbirth. But campaigners and lawyers told The Independent their guidance for visitor restrictions in maternity services during the pandemic is legally inaccurate as people have the “right to private and family life” under Article Eight of the Human Rights Act. M -
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Note: Subtitles are available by turning on the caption mode in YouTube. Would you like to share your insight on the continuity of care model? Perhaps you know women and families who would like to share their experience? You can get in touch with Patient Safety Learning by emailing us at content@pslhub.org Further reading: Measuring Continuity of Carer: A monitoring and evaluation framework (November 2018) NHS: Targeted and enhanced midwifery-led continuity of carer RCM: Can continuity work for us? A resource for midwives -
News Article
Making maternity wards safer for mothers and babies will need £400m of extra spending every year, hospital leaders have told The Independent. They warn that without increased funding, the NHS will not be able to fully implement recommendations made by an inquiry into poor maternity care at the Shrewsbury and Telford Hospitals Trust – where dozens of babies died or were left brain damaged in the largest maternity scandal in NHS history. Multiple maternity care failings at hospitals across the country in the past 12 months have sparked concerns over the safety of mothers and their babi -
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More deaths, worse care: inquiry opens into NHS maternity ‘systemic racism’
Patient Safety Learning posted a news article in News
An urgent inquiry to investigate how alleged systemic racism in the NHS manifests itself in maternity care will be launched on Tuesday with support from the UK charity Birthrights. The inquiry will apply a human rights lens to examine how claimed racial injustice – from explicit racism to bias – is leading to poorer health outcomes in maternity care for ethnic minority groups. Data published last month by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the country) showed black women were four times more likely than white women to die in -
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Group B Strep Support recommends that: All NHS Trusts/Boards adopt and implement the Royal College of Obstetricians & Gynaecologists’ Green-top guideline on group B Strep promptly. All pregnant women are provided with a high-quality information leaflet on group B Strep as a routine part of their antenatal care. Pregnant women who had a positive test result for group B Strep in a previous pregnancy are offered the option of testing for group B Strep in the current pregnancy, or of being treated as a carrier this pregnancy. Where pregnant women are offered testing for- Posted
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The majority of recommendations which MBRRACE-UK assessors have identified to improve care are drawn directly from existing guidance or reports and denote areas where implementation of existing guidance needs strengthening. In a small number of instances, actions are needed for which national guidelines are not available. These are included below. To access the report and the full list of recommendations, please click on the link at the bottom of this page. New recommendations to improve care: For professional organisations 1. Develop guidance to ensure SUDEP awareness, risk asse- Posted
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New training for NHS maternity staff to boost babies safety
Patient Safety Learning posted a news article in News
Hundreds of senior midwives are to be given new training to help improve culture and leadership across 126 NHS trusts. Patient safety minister Nadine Dorries said a new £500,000 maternity leadership programme would be rolled out later this year aimed at giving senior staff running maternity wards the skills and knowledge they need to boost culture and safety. Its one step towards improving the working relationships between midwives and obstetricians and follows the damning report by the Ockenden inquiry into decades of poor care at Shrewsbury and Telford Hospitals Trust. The rep- Posted
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Covid crisis forces suspension of maternity services
Patient Safety Learning posted a news article in News
Some trusts in London and the South East are closing standalone birth centres and warning they cannot support home births because of high levels of demand for ambulance services from covid patients. Women in East Sussex who planned to give birth at Eastbourne District General Hospital and Crowborough Birth Centre have been told they need to go to other units. Both Eastbourne and Crowborough have standalone midwife-led units and women who have a difficult labour would need to be transferred by ambulance to another hospital. Both East Sussex Healthcare Trust and Maidstone and Tunbridge -
News Article
In a Letter to the Editor published in The Times yesterday, the All Party Parliamentary Group on First Do No Harm Co-Chair Baroness Julia Cumberlege argues in favour of the work of the Independent Medicines and Medical Devices Safety (IMMDS) Review and its report 'First Do No Harm'. "Inquiries are only as good as the change for the better that results from their work." Read full letter (paywalled) Source: The Times, 5 January 2021- Posted
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People with allergies and pregnant women can now be given the country’s two approved COVID-19 vaccines, the medical regulator said on Wednesday. Previous advice from the Medicines and Healthcare products Regulatory Agency (MHRA) said people with a range of allergies to food and medicines should not be given the Pfizer vaccine. Dr June Raine, the MHRA’s chief executive, said growing evidence from a pool of at least 800,000 people in the UK and around 1.5 million people in the US who have had the vaccine has "raised no additional concerns". This, she continued, "gives us further a- Posted
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LATEST Patient Safety Weekly Update #21 (18 February 2020) Patient Safety Weekly Update #20 (11 February 2020) Patient Safety Weekly Update #19 (4 February 2020) Patient Safety Weekly Update #18 (28 January 2020) Patient Safety Weekly Update #17 (21 January 2020) Patient Safety Weekly Update #16 (14 January 2020) Patient Safety Weekly Update #15 (7 January 2020) Patient Safety Weekly Update #14 (17 December 2020) Patient Safety Weekly Update #13 (10 December 2020) Patient Safety Weekly Update #12 (3 December 2020) Patient Safety Weekl -
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A new training aid, developed in Fife, is helping to equip trainee medical staff from around the world with the skills to prevent late miscarriage and premature labour. It was invented by Dr Graham Tydeman, consultant in obstetrics and gynaecology at Kirkcaldy’s Victoria Hospital, in conjunction with the St Thomas’ Hospital, London, and Limbs and Things. The lifelike simulator allows trainees to perform hands on cervical cerclage in advance of a real-life emergency. The procedure involves an emergency stitching around the cervix and is necessary when the cervix shortens or opens too -
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Shropshire baby deaths: Hospitals must adopt new safety steps
Patient Safety Learning posted a news article in News
All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes- Posted
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Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has be