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Found 803 results
  1. Content Article
    Improving maternity care is a key Government and National Institute for Health and Care Research (NIHR) priority. In March 2024, an NIHR Evidence webinar showcased research from their recent Collection, Maternity services: evidence to support improvement.  This summary includes videos of researchers’ presentations and captures some of the points raised in the webinar Q&A. It highlights seven features of safety in the maternity units, kind and compassionate care around the induction of labour, and the role of hospital boards in improving maternity care.
  2. Content Article
    When ECRI unveiled its list of the leading threats to patient safety for 2024, some items are likely to be expected, such as physician burnout, delays in care due to drug shortages or falls in the hospital. However, ECRI, a non-profit group focused on patient safety, placed one item atop all others: the challenges in helping new clinicians move from training to caring for patients. In an interview with Chief Healthcare Executive®, Dr. Marcus Schabacker, president and CEO of ECRI, explained that workforce shortages are making it more difficult for newer doctors and nurses to make the transition and grow comfortably. “We think that that is a challenging situation, even the best of times,” Schabacker says. “But in this time, these clinicians who are coming to practice now had a very difficult time during the pandemic, which was only a couple years ago, to get the necessary hands-on training. And so we're concerned about that.”
  3. News Article
    Norah Bassett was hours old when she died in 2019, after multiple failings in her care. What can be learned from her heartbreaking loss? The maternity unit at the Royal Hampshire county hospital in Winchester was busy the evening when Charlotte Bassett gave birth. When the night shift came on duty, a midwife introduced. “She was very brusque,” Charlotte, 37, a data manager, remembers. “She said, ‘We’ve got too many people here. I’ve got this and this to do.’” Charlotte tried to breastfeed Norah, but she wasn’t latching. The midwife told Charlotte to cup feed her with formula. She didn’t stay to watch. Charlotte poured milk from a cup into Norah’s rosebud mouth. Blood came out. It was staining the muslin. The midwife didn’t seem concerned. “I was drowning my child, who was drowning in her own blood. And there was no one there to say: this isn’t normal,” Charlotte says. The Health Services Safety Investigations Body (now HSSIB but at the time known as HSIB), which investigates patient safety in English hospitals, produced a report into Norah’s care in 2020. One sentence leaped out to Charlotte and her husband James. “An upper airway event (such as occlusion of the baby’s airway during skin-to-skin) may have contributed to the baby’s collapse.” In other words, it was possible that Charlotte might have smothered her daughter. “So Charlotte spent four years in agony,” says James, “thinking it was her.” Dr Martyn Pitman remembers the night Norah died, because it was unusual. A crash call, for a baby born to a low-risk mother. It played on his mind, because eight days earlier, on 4 April 2019, Pitman, a consultant obstetrician and gynaecologist, had presented proposals for enhanced foetal monitoring to a meeting of the maternity unit’s doctors and senior midwives. Pitman, 57, who is an expert in foetal monitoring, felt the proposals would prevent more babies suffering brain injuries at birth. “We’re not that good at detecting the high-risk baby, in the low-risk mum,” he says. Another doctor would later characterise the meeting as “hideous … hands down the worst meeting I’ve ever been to. Martyn … was being set upon.” A midwife felt the animosity in the room was “personal towards Martyn”, and was “appalled” by the “unprofessionalism that I saw from my midwifery colleagues”. James and Charlotte join an unhappy club: a community of parents whose children died young, after receiving poor care, and were told their deaths were unavoidable, or felt blamed for them. “I’ve spoken to so many families,” says Donna Ockenden, who authored a 2022 report into Shrewsbury’s maternity services, “who have been blamed for the eventual poor outcome in their cases. This has included being blamed for their babies’ death.” She has also met the families of women blamed for their own deaths. “This never fails to shock me,” she says. Read full story Source: The Guardian, 26 March 2024
  4. Content Article
    In this Guardian article, Theopi Skarlatos explains how she was making a documentary about the UK’s midwife crisis when she lost her baby. By then she had heard time and again about understaffing, depression, burnout …
  5. News Article
    The UK’s National Institute for Health and Care Research (NIHR) has launched a £50m “Challenge” funding call to tackle inequalities in maternity care. The funding call aims to establish a research consortium to deliver research and capacity building over five years. The call was announced as part of the Department for Health and Social Care’s women’s health priorities for 2024. Recent evidence suggests that Black women in the UK are almost three times more likely to die during pregnancy or up to six weeks after pregnancy compared to white women. Asian women are twice as likely to die during pregnancy or shortly after, compared to white women. The new consortium is hoped to bring together experts across the UK to help change numbers like these. The research aims to focus on inequalities before, during and after pregnancy. According to NIHR, a key aim is to identify specific areas where measurable improvements can be made. Relevant charities, patient groups, community groups and the life sciences industry will be involved in the research where appropriate. Professor Marian Knight, scientific director for NIHR Infrastructure, said: “I am hugely excited about what this research can achieve – funding truly innovative approaches to tackle maternity inequalities will save women’s and babies’ lives – this is a challenge the NIHR is ideally placed to deliver.” Read full story Source: FemTech World, 15 March 2024
  6. News Article
    Alice and Lewis Jones were forced to watch their 18-month-old baby die in front of them after a failure by a scandal-hit NHS trust left him with a “catastrophic brain injury” following his birth. Their son Ronnie was one of hundreds of babies who have died following errors by Shrewsbury and Telford Hospital, where the largest NHS maternity scandal to date was previously uncovered by The Independent. Two years later, Mr and Mrs Jones are calling for the Supreme Court to overturn a controversial decision in February which ruled bereaved relatives could not claim compensation over the psychological impact of seeing a loved one die, even if it was caused by medical negligence. It comes after the trust admitted to failings in a letter to the parents’ lawyers. Ronnie’s birth in 2020 fell outside of the Ockenden review and his parents have warned it showed failures were still occurring despite warnings made during the inquiry. Within the Ockenden inquiry, multiple cases of staff failing to recognise and act upon CTG training were found, and the final report recommended all hospitals have systems to ensure staff are trained and up to date in CTG and emergency skills. The report also said the NHS should make CTG training mandatory and that clinicians must not work in labour wards or provide childbirth care without it. A CTG measures a baby’s heart and monitors conditions in the uterus and is an important measure before birth and during labour to observe the baby for any signs of distress. Ms Jones said: “We knew about the Ockenden review, but everything at Telford was new and so I think we just assumed that lessons had been learned, the same thing wouldn’t happen to us.” Ronnie’s parents are campaigning to reverse the Supreme Court which ruled that “secondary victims” – including parents who are not directly harmed by the birth – are not eligible to bring claims for psychiatric injury following medical negligence. Read full story Source: The Independent, 14 March 2024
  7. News Article
    Almost £35 million will be invested to improve maternity safety across England with the recruitment of additional midwives and the expansion of specialist training to thousands of extra healthcare workers. The investment, which was announced as part of the Spring Budget 2024, will be provided over the next 3 years to ensure maternity services listen to and act on women’s experiences to improve care. The funding includes: £9 million for the rollout of the reducing brain injury programme across maternity units in England, to provide healthcare workers with the tools and training to reduce avoidable brain injuries in childbirth investment in training to ensure the NHS workforce has the skills needed to provide ever safer maternity care. An additional 6,000 clinical staff will be trained in neonatal resuscitation and we will almost double the number of clinical staff receiving specialist training in obstetric medicine in England increasing the number of midwives by funding 160 new posts over 3 years to support the growth of the maternity and neonatal workforce funding to support the rollout of maternity and neonatal voice partnerships to improve how women’s experiences and views are listened to and acted on to improve care. Health and Social Care Secretary Victoria Atkins said: "I want every mother to feel safe when giving birth to their baby. Improving maternity care is a key cornerstone of our Women’s Health Strategy and with this investment we are delivering on that priority - more midwives, specialist training in obstetric medicine and pushing to improve how women are listened to in our healthcare system. £35 million is going directly to improving the safety and care in our maternity wards and will move us closer to our goal of making healthcare faster, simpler and fairer for all." Read full story Source: Gov.UK, 10 March 2024
  8. Content Article
    This annual report from ECRI and the Institute for Safe Medication Practices (ISMP) presents the top 10 patient safety concerns currently confronting the healthcare industry. It is a guide for a systems approach to adopting proactive strategies and solutions to mitigate risks, improve healthcare outcomes and enhance the well-being of patients and the healthcare workforce. Drawing on ECRI and ISMP’s evidence-based research, data and insights, this report sheds light on issues that leaders should evaluate within their own institutions as potential opportunities to reduce preventable harm. Some of the concerns represent emerging risks, some are well known but still unresolved, but all of them pertain to areas where organisations can make meaningful change.
  9. News Article
    The NHS paid out tens of millions of pounds over maternity failings at a hospital trust which is the subject of a major inquiry. Including legal fees, £101m was paid in claims against Nottingham University Hospitals (NUH) between 2006 and 2023. NUH is facing the UK's largest-ever maternity review, with hundreds of baby deaths and injuries being examined. Experts say lives could be saved if the trust invested more in learning from its mistakes. The NHS paid the money in relation to 134 cases over failings at the Queen's Medical Centre (QMC) and City Hospital. The majority - £85m - was damages for families who were successful in proving their baby's death or injury was a result of medical negligence. Read full story Source: BBC News, 28 February 2024
  10. Content Article
    Spina bifida develops early in the embryonic stage of pregnancy but is not usually detected until the midterm (20 week) ultrasound scan.  Shine conducted a survey to assess the antenatal care experiences of parents to children with spina bifida. Volunteers were recruited via social media and 71 eligible (UK-based) responses were received, revealing numerous elements of antenatal care in need of significant improvement. Shine have published the findings and recommendations for improving antenatal diagnosis and care for spina bifida. 
  11. Content Article
    Despite its reported benefits, breastfeeding rates are low globally, and support systems such as the Baby Friendly Initiative (BFI) have been established to support healthy infant feeding practices and infant bonding. Increasingly reviews are being undertaken to assess the overall impact of BFI accreditation. A systematic synthesis of current reviews has therefore been carried out to examine the state of literature on the effects of BFI accreditation. 
  12. Content Article
    In this Lancet article, Lioba Hirsch shares her experience of labour and birth as a Black woman. She describes dismissive behaviours and blaming comments from several healthcare professionals that left her feeling unable to ask questions and advocate for herself and her baby. She suggests that the lack of compassion and dignity she was shown are a risk to patient safety: "I am so glad that my child was safe that day, but many children and their birthing parents are not and the slope from disrespect and disregard to dismissal and its consequences is a slippery one."
  13. Content Article
    This BMJ article summarises a selection of new and updated recommendations within The National Institute for Health and Care Excellence (NICE) guidelines on intrapartum care for healthy women and babies.
  14. Content Article
    In this long-read article, Abbie Mason-Woods talks about her experience of having a high-risk pregnancy, pre-term birth and two baby girls in a Neonatal Intensive Care Unit (NICU). Abbie shares her deep insights as a patient and parent, highlighting the importance of trauma-informed, person-centred care throughout the care pathway, and the risk in forgetting the mother. 
  15. News Article
    A trust’s main maternity unit has been rated “inadequate” and given a warning notice amid concerns delayed Caesarean sections are causing harm to babies. The Care Quality Commission (CQC) told Maidstone and Tunbridge Wells Trust to make significant improvements in how quickly it carries out emergency C-sections, the regulator said in a report today. The trust was also told to improve risk management, governance and oversight of services at its Tunbridge Wells Hospital. Inspectors found between April and July last year, 42% of “category 1” emergency Caesareans – defined as those posing an immediate threat to the life of the woman or foetus — at the Tunbridge Wells Hospital were delayed. The National Institute for Health and Care Excellence says these should be carried out “as soon as possible and in most situations within 30 minutes of making the decision”. The report identified “ongoing recurrent delays” to emergency Caesareans overnight, as the trusts did not have a second theatre available. This “meant an increased risk of harm, including cases reported by the service such as babies with ‘acute foetal hypoxia’ had emerged due to delayed births”, the inspection report said. It also criticised the trust for not responding to a high level of post-partum haemorrhages, some of which had caused “moderate” harm. Read full story (paywalled) Source: HSJ, 16 February 2024
  16. News Article
    "Cultural and ethnic bias" delayed diagnosing and treating a pregnant black woman before her death in hospital, an investigation found. The probe was launched when the 31-year-old Liverpool Women's Hospital patient died on 16 March, 2023. Investigators from the national body the Maternity and Newborn Safety Investigations (MSNI) were called in after the woman died. A report prepared for the hospital's board said that the MSNI had concluded that "ethnicity and health inequalities impacted on the care provided to the patient, suggesting that an unconscious cultural bias delayed the timing of diagnosis and response to her clinical deterioration". "This was evident in discussions with staff involved in the direct care of the patient". The hospital's response to the report also said: "The approach presented by some staff, and information gathered from staff interviews, gives the impression that cultural bias and stereotyping may sometimes go unchallenged and be perceived as culturally acceptable within the Trust." Liverpool Riverside Labour MP Kim Johnson said it was "deeply troubling" that "the colour of a mother's skin still has a significant impact on her own and her baby's health outcomes". Read full story Source: BBC News, 16 February 2024
  17. News Article
    There was an “unacceptable delay” and “failure to act with candour” in how a trust responded to a serious risk from staff nitrous oxide exposure, an independent investigation has found. Mid and South Essex Foundation Trust found levels of nitrous oxide far above the workplace exposure limit at Basildon Hospital’s maternity unit during routine testing in 2021. However, staff were only notified and a serious incident declared more than a year later. The exposure related to a mixture of nitrous oxide and oxygen, commonly known as gas and air, used during births. While short-term exposure is considered safe, prolonged exposure to nitrous oxide could lead to potential health issues. Chief executive Matthew Hopkins has apologised, after a report by the Good Governance Institute said: “The inquiry found that there was an unacceptable delay in responding to and mitigating a serious risk that had been reported… As a result of this failure to act on a known risk, midwives and staff members on the maternity unit were exposed to unnecessary risk or potential harm from July 6 2021 to October 2022." Read full story (paywalled) HSJ, 14 February 2024
  18. Content Article
    With the Maternity and Newborn Safety Investigations transition to the Care Quality Commission (CQC) completed, Sandy Lewis, Director of the Maternity Investigation Programme, reflects on past accomplishments, ambitions for 2024 and how the CQC transition is bedding in.
  19. News Article
    The trusts where maternity care has deteriorated the most according to patient surveys have been identified by the Care Quality Commission. The regulator collected responses from 25,515 patients about their experiences of antenatal care, labour, birth and postnatal care across 121 trusts in February 2023. It then analysed where experiences of care were substantially better or worse overall when compared with survey results across all trusts in England. Survey responses also painted a deteriorating picture of maternity care nationally, with answers to 11 questions showing a statistically significant downward trend compared to five years ago. Five trusts were categorised as “worse than expected”, where patients’ experiences of using their services were substantially worse than the average. Read full story (paywalled) Source: HSJ, 12 February 2024
  20. News Article
    Lawyers and charities tell of mothers told to ‘labour at home as long as they can’, dangerously few midwives and ‘lies’ during natal care. As Rozelle Bosch approached her due date she had every reason to expect a healthy baby. Neither she, her husband nor the midwives knew that the child was in the breech position at 30 weeks. When her waters broke a fortnight early, Bosch and her husband, Eckhardt, both first-time parents, had been reassured by NHS Lanarkshire that all was well and that the mother was “low risk”. They were sent home from Wishaw hospital and told to monitor conditions until the pregnancy became “active”. Shortly before 11pm on 1 July 2021, her husband called an ambulance saying that Bosch was in labour and was giving birth. Bosch was in an upstairs bedroom on her knees and paramedics noted that “the baby was pink”. They soon asked the control room for a doctor or midwife to attend but none were available. By the time the ambulance took the family to hospital, the baby had turned blue. Within two days, baby Mirabelle had died. She had become trapped with only her feet and calves delivered while the couple were still at home. A post-mortem has found that Mirabelle suffered oxygen deprivation to the brain from “head entrapment” during delivery. Last month, her father explained to a fatal accident inquiry (FAI) at Glasgow sheriff court: “We were told Rozelle was healthy and Mirabelle was healthy. I think this was a lie and the consequences have me standing here today.” The way that the tragedy unfolded is striking, not just because of the devastating consequences, but because it is not an entirely isolated case. The same FAI is examining the deaths of two other newborns, Ellie McCormick and Leo Lamont, who also died in NHS Lanarkshire less than a month apart in 2019. Experts say it is rare for the Crown and Procurator Fiscal Service to group investigations in this way. Darren Deery, the McCormicks’ lawyer and a medical negligence specialist with Drummond Miller, said he had noticed a “considerable increase” in parents contacting the law firm in the past three years. Read full story (paywalled) Source: The Times, 11 February 2024
  21. Content Article
    The relationship between the fields of human factors and patient safety is relatively nascent but represents a powerful interaction that has developed in only the last twenty years. Application of human factors principles, techniques, and science can facilitate the development of healthcare systems, protocols, and technology that leverage the enormous and adaptable capacity of human performance while acknowledging human vulnerability and decreasing the risk of error during patient care. This chapter will review these concepts and employ case studies from neonatal care to demonstrate how an understanding of human factors can be applied to improve patient safety.
  22. News Article
    The NHS Race and Health Observatory, in partnership with the Institute for Healthcare Improvement and supported by the Health Foundation, has established an innovative 15-month, peer-to-peer Learning and Action Network to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Across England, nine NHS Trusts and Integrated Care Systems will participate in this action oriented, fast-paced Learning and Action Network to improve outcomes in maternal and neonatal health. Through the Network, the nine sites will aim to address the gaps seen in severe maternal morbidity, perinatal mortality and neonatal morbidity between women of different ethnic groups. Haemorrhage, preterm birth, post-partum depression and gestational diabetes have been identified as some of the priority areas for the programme. The sites will generate tailored action plans with the aim of identifying interventions and approaches that reduce health inequalities and enhance anti-racism practices and learning from the programme. These will be evaluated and shared across and between healthcare systems. The Network, the first of its kind for the NHS, will combine Quality Improvement methods with explicit anti-racism principles to drive clinical transformation, and aims to enable system-wide change. Over a series of action, learning and coaching sessions, participants will review policies, processes and workforce metrics; share insights and case studies; and engage with mothers, parents, pregnant women and people. The programme will run until June 2025, supported by an advisory group from the NHS Race and Health Observatory, Institute for Healthcare Improvement, and experts in midwifery, maternal and neonatal medicine. Read full story Source: NHS Race and Health Observatory, 24 January 2024
  23. Content Article
    Drawing upon the findings of a PhD that captured the experiences of midwives who proactively supported alternative physiological births while working in the National Health Service, their practice was conceptualised as ‘skilled heartfelt practice’. Skilled heartfelt practice denotes the interrelationship between midwives’ attitudes and beliefs in support of women’s choices, their values of cultivating meaningful relationships, and their expert practical clinical skills. It is these qualities combined that give rise to what is called ‘full-scope midwifery’ as defined by the Lancet Midwifery Series. This book illuminates why and how these midwives facilitated safe, relational care. Using a combination of emotional intelligence skills and clinical expertise while centring women’s bodily autonomy, they ensured safe care was provided within a holistic framework. 
  24. Content Article
    Join Alan Lindemann, an obstetrics-gynecology physician, who shares his insights and real-life experiences, shedding light on the issues surrounding patient care, medical decision-making, and the role of institutions and personal connections in shaping health care outcomes. Discover how the pursuit of quality care can sometimes be obstructed by self-interest and the need to protect reputations. Alan also proposes innovative ideas to enhance transparency and public involvement in health care quality assurance.
  25. Content Article
    In this animation, the Nursing and Midwifery Council (NMC) look at speaking up and what this means for you as a registered professional.
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