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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 -
News Article
Herpes deaths: NHS trust lied about virus links, inquest hears
Patient Safety Learning posted a news article in News
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 -
News Article
‘They didn’t believe I was in labour’ says Black mother ‘ignored’ by midwives
Patient Safety Learning posted a news article in News
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 -
News Article
Northern Ireland new model of care for pregnant women launching
Patient Safety Learning posted a news article in News
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 -
News Article
End racial disparities in maternal deaths
Patient Safety Learning posted a news article in News
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. -
News Article
Trusts given five years to achieve safe midwife staffing
Patient Safety Learning posted a news article in News
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 -
News ArticleMothers 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
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News Article
Specialist NHS centres aim to halve maternity deaths in England
Patient Safety Learning posted a news article in News
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 -
News Article
Birmingham hospital apologises after delays leave baby disabled
Patient Safety Learning posted a news article in News
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 -
News Article
Conference highlights racial disparity in UK maternal healthcare
Patient Safety Learning posted a news article in News
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. -
News Article
Why US mothers are more likely to die in childbirth
Patient Safety Learning posted a news article in News
The United States remains one of the most dangerous wealthy nations for a woman to give birth. Maternal mortality rose by 40% at the height of the pandemic, according to new data released by the US Centers for Disease Control and Prevention. In 2021, 33 women died out of every 100,000 live births in the US, up from 23.8 in 2020. That rate was more than double for black women, who were nearly three times more likely to die than white women, according to the CDC. Compared to other countries, the maternal mortality rate was twice as high in the US than in the UK, Germany and France; and three times higher than in Spain, Italy, Japan and several other countries, according to the most recent global comparison data kept by the World Bank. "Clearly the US is an outlier," said Joan Costa-i-Font, a professor of health economics at the London School of Economics. "Covid has made [maternal mortality] worse, but it was already a major issue in the US." Read full story Source: BBC News, 18 March 2023 -
Content Article
A Black woman is 3.7 times more likely to die in pregnancy than a white woman. [1] They are more likely to experience postnatal depression.[2] and less likely to seek support.[3]. Mental ill-health in pregnancy and beyond is an increasing cause of maternal death,[1] making it more important than ever to understand and address racial inequality. In this interview, we talk to Sandra Igwe, CEO of The Motherhood Group, and Author of My Black Motherhood: Mental Health, Stigma, Racism and the System, about the Black Maternal Health Conference UK, taking place on 20 March 2023. Sandra, who is hosting the event, explains how the day has been designed to support the rebuilding of trust between Black mothers and the healthcare system. She introduces us to the rich and interactive agenda and explains how it will provide opportunity for deeper exploration and collaboration. Sandra welcomes everyone to sign up to the event, from mothers and healthcare professionals to researchers and journalists. Event hashtag - #BMHCUK -
Content ArticleIn this book, Sandra Igwe shares her journey as a young Black mother, coping with sleepless nights, anxiety and loneliness after the birth of her first daughter. Burdened by cultural expectations of the 'good mother' and the 'strong Black woman' trope, her mental health struggles became an uphill battle. Black women are at higher risk of developing postnatal depression but are the least likely to be identified as depressed. Sharing the voices of other mothers, Sandra examines how culture, racism, stigma and a lack of trust in services prevent women getting the help they need. Breaking open the conversation on motherhood, race, and mental health, she demands that Black women are listened to, believed, and understood.
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Content ArticleWomen and birthing people from black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey. Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what could be done to improve local services. This is the first in a series of blogs published by the Health Innovation Network, reflecting on the learnings and experiences from her Fellowship.
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Content ArticleThe Health and Social Care Select Committee have published a new report reviewing 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 blog sets out Patient Safety Learning’s reflections on this report.
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Content ArticleThis Health and Social Care Select Committee report reviews 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. You can read Patient Safety Learning’s reflections on this report here.
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Content ArticleInstitute of Health Visiting executive director Alison Morton warns national policy has developed a “baby blind spot” amid the NHS crisis, with many young children missing out on government’s promise of the “best start in life”, and calls for a shift towards prevention and early intervention.
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Content Article
CQC: Maternity survey 2022
Patient Safety Learning posted an article in Maternity
This survey from the Care Quality Commission (CQC) looked at the experiences of women and other pregnant people who had a live birth in early 2022. -
Content ArticleGlobally, the under-five mortality rate (U5MR) fell to 38 deaths per 1,000 live births in 2021, while under-five deaths dropped to 5.0 million. Although this demonstrates a decrease, this immense, intolerable and mostly preventable loss of life was carried unequally around the world , and children continue to face widely differing chances of survival based on where they are born. In contrast to the global rate, children born in sub-Saharan Africa are subject to the highest risk of childhood death in the world with a 2021 U5MR of 74 deaths per 1,000 live births – 15 times higher than the risk for children in Europe and Northern America and 19 times higher than in the region of Australia and New Zealand This report outlines and analyses figures from The United Nations Inter-Agency Group for Child Mortality Estimation (UN IGME) to examine levels and trends in child mortality around the world during 2022.
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Content ArticleOn the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost
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Content ArticleThis is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
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Content ArticlePaul Batalden is the host of "The Power of Coproduction". Prepared as a pediatric physician, he has been an international architect, teacher, and advocate for the improvement of healthcare services for five decades. His current focus is the coproduction of healthcare services.
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Content ArticleMaternal Mortality Review Committees (MMRCs) in the US are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within a year of pregnancy. MMRCs have access to clinical and non-clinical information to more fully understand the circumstances surrounding each death, determine whether the death was pregnancy-related, and develop recommendations for action to prevent similar deaths in the future. This article summarises the data from MMRCs in 36 US states between 2017 and 2019, demonstrating variations in prevalence and cause of death according to race, ethnicity and geographical area. The data suggests that over 80% of pregnancy-related deaths examined were determined to be preventable.
