Jump to content

Search the hub

Showing results for tags 'Maternity'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Patient Safety Alerts
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End

Group

First name

Last name

Country

About me

Organisation

Role

Found 500 results
  1. Event
    until
    The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI's findings following a systematic literature review analysing the research regarding cord management during neonatal transition and resuscitation. Register for the webinar
  2. Event
    until
    The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore factors affecting the delivery of safe care in midwifery units following the analysis of 92 randomly selected cases where care had been given at some time during labour on a birth centre. Register for the webinar
  3. Event
    until
    The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore MNSI’s Health Equity Warning Score (HEWS) and the Health Equity Assessment and Resource Toolkit (HEART). MNSI's health equity, diversity and inclusion leads developed this assessment tool to systematically identify, acknowledge, investigate and analyse factors affecting health equity which impact care and perinatal outcomes. Join this webinar to find out how you can put this tool into practice in your trust. Register for the webinar
  4. Event
    until
    The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. MNSI made recommendations to trusts 33 times between September 2018 and December 2023 in relation to birthing outside of guidance. These were reviewed by a team of maternity investigators and clinical advisors who identified this as a learning theme. In this webinar we will explore how healthcare professionals are able to support women / birthing people who birth outside of guidance so we can improve the outcomes and the experience of mothers, birthing people and babies. Register for the webinar
  5. Event
    until
    The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. For every 1000 babies born, 1-2 need assistance (2-10% of these need intubation). In this webinar we will explore learnings following a review of hypoxic ischaemic injuries (HIE) or early neonatal deaths (ENND). Register for the webinar
  6. Content Article
    Recent reports have highlighted issues with non-English speaking women and birthing people being able to access equitable maternity care, with inconsistent use of interpreters and translation services, and cases where this has contributed to poor outcomes and avoidable harm. Sands & Tommy’s Joint Policy Unit have produced a briefing paper on translation and interpreting services in maternity and neonatal care. Key messages • Reports and reviews have highlighted issues with the use and quality of interpreting and translation services in maternity care, contributing to poor outcomes and avoidable harm. • Existing guidance states that professional interpreting services must always be available when needed, and that family members should not be used in place of a professional interpreter. • There is poor documentation of interpreting need, and inadequate response to requests for interpretation. • Where interpreting and translation services are available, they are not used consistently. Barriers to this include limited appointment time and poor quality of services. • Lack of high-quality interpreting services are also impacting personalisation of care and choice, and women and birthing people’s ability to give informed consent to treatment and procedures. Follow the link below to read the full briefing paper.
  7. News Article
    "Reasonable precautions" could have prevented the deaths of three newborn babies, a fatal accident inquiry has found. Leo Lamont, Ellie McCormick and Mira-Belle Bosch all died within hours of their births in two Lanarkshire hospitals, in 2019 and 2021. The report found all three deaths could "realistically" have been avoided had different advice been given by midwives or procedures followed. The McCormick family said they could "never have imagined" the amount of failures that led to their daughter's death and called it a "catalogue of errors". The inquiry ruled "defects" within the system contributed to each death, including that there was a "lack of an effective means" to highlight risks in one of the pregnancies and that midwives had no guidance to assess preterm labour symptoms. Sheriff Principal Aisha Anwar KC made 11 recommendations for the future, including creating a "trigger list" to identify and assess early labour symptoms. Among these are reviewing electronic patient information records to improve alerts for at risk mothers, and having a direct telephone line to each maternity unit in Scotland for ambulance crews. In a statement, the McCormick family said: "The family could simply never have imagined the scale of both the individual and systems failures that came to light during the inquiry. "What seemed to be flaws with the electronic system of record keeping actually turned out to be a catalogue of errors with numerous opportunities to avoid the tragic outcome that followed." Read full story Source: BBC News, 18 March 2025
  8. Content Article
    PROMPT Wales is a maternity safety and learning programme funded by the Welsh Risk Pool and supported by the PROMPT Maternity Foundation. This all Wales programme aims to meet the training needs of multi-professional teams in NHS Wales maternity services. PROMPT Wales is delivered in all 7 Health Boards in Wales by local faculty teams. Programmes include the clinical management of obstetric emergencies with a focus on teamworking, communication and the impact of human factors. Training is situated in the clinical setting and ‘teams who work together, train together.’ The overall aim of PROMPT Wales is to improve outcomes in maternity care and reduce the litigation costs associated with avoidable harm.
  9. Content Article
    More information about "World Patient Safety Day 2025"
    This year’s World Patient Safety Day on 17 September is focused on the theme “Safe care for every newborn and every child”. This article explains the aims of the event and the areas it will cover. Wednesday 17 September 2025 marks the sixth annual World Patient Safety Day. World Patient Safety Day aims to: increase public awareness and engagement enhance global understanding work towards global solidarity and action by World Health Organization (WHO) Member States to enhance patient safety and reduce patient harm. The theme of this year’s event is “Safe care for every newborn and every child”.[1] Ensuring safe care for patients is a fundamental priority, yet newborns and children remain especially vulnerable to patient safety risks. While the reported level of patient safety incidents relating to newborns and children receiving healthcare varies, studies suggest that adverse events occur across all care settings, with higher risks among critically ill children, particularly those in intensive care or requiring complex medical interventions. Some studies report rates as high as 91.6% in intensive care settings and up to 53.8% in general care settings.[2] To bring attention this critical issue, “Safe care for every newborn and every child” has been selected as the theme for World Patient Safety Day 2025, emphasising the need for stronger measures to protect children from preventable harm. The Global Patient Safety Action Plan 2021–2030 recognises paediatric and newborn safety across multiple strategic objectives, including designing safe clinical processes, strengthening health workforce competencies, engaging patients and families and establishing learning systems to prevent harm. Objectives of World Patient Safety Day 2025 Under the slogan “Patient safety from the start!”, WHO is calling for urgent action to eliminate avoidable harm in paediatric and newborn care. Addressing this challenge requires comprehensive efforts across key patient safety areas, such as safe childbirth and postnatal care, medication safety, diagnostic safety, immunisation safety, infection prevention and early recognition of clinical deterioration. World Patient Safety Day 2025 aims to drive meaningful improvements and reaffirm every child's right to safe and quality care. As part of this, it has set four objectives: Raise global awareness of safety risks in paediatric and newborn care in all health care settings, emphasising the specific needs of children, families and caregivers. Mobilise governments, health care organizations, professional bodies and civil society to implement sustainable strategies for safer care for newborns and children as part of broader patient safety and quality initiatives. Empower parents, caregivers and children in patient safety by promoting education, awareness and active participation in care. Advocate for Strengthening research on patient safety in paediatric and newborn care. Share your views and experiences on the hub Do you have experiences or views around the theme of this year’s World Patient Safety Day that you would like to share? You can share your thoughts with us by commenting below (sign up here for free first), submitting a blog, or by emailing us at [email protected]. References WHO. Announcing World Patient Safety Day 2025 – Patient safety from the start!, 18 March 2025. Dillner P, Eggenschwiler LC, Rutjes AWS, Berg L, Musy SN, Simon M et al. Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis. BMJ Qual Saf. 2023;32:133–49.
  10. Content Article
    Haemorrhage – severe heavy bleeding – and hypertensive disorders like preeclampsia are the leading causes of maternal deaths globally, according to a new study by the World Health Organization (WHO). These conditions were responsible for around 80 000 and 50 000 fatalities respectively in 2020 – the last year for which published estimates are available – highlighting that many women still lack access to lifesaving treatments and effective care during and after pregnancy and birth. Published in the Lancet Global Health, the study is WHO’s first global update on the causes of maternal deaths since the United Nations’ Sustainable Development Goals were adopted in 2015. In addition to outlining the major direct obstetric causes, it shows that other health conditions, including both infectious and chronic diseases like HIV/AIDS, malaria, anaemias, and diabetes, underpin nearly a quarter (23%) of pregnancy and childbirth-related mortality. These conditions, which often go undetected or untreated until major complications occur, exacerbate risk and complicate pregnancies for millions of women around the world. “Understanding why pregnant women and mothers are dying is critical for tackling the world’s lingering maternal mortality crisis and ensuring women have the best possible chances of surviving childbirth,” said Dr Pascale Allotey, Director of Sexual and Reproductive Health and Research at WHO as well as the UN’s Special Programme on Human Reproduction (HRP). “This is also a massive equity issue globally - women everywhere need high quality, evidence-based health care before, during and after delivery, as well as efforts to prevent and treat other underlying conditions that jeopardize their health.”
  11. News Article
    Rural hospitals across the United States fear massive Medicaid cuts favored by the Republican Party could decimate maternity services or shutter already struggling medical facilities in communities that overwhelmingly voted for Donald Trump. Nearly half of all rural hospitals nationwide operate at a deficit, with Medicaid barely keeping them afloat. Already, almost 200 rural hospitals have closed in the past two decades, according to the Cecil G. Sheps Center for Health Services Research, part of the University of North Carolina at Chapel Hill. Rural hospital leaders in Arkansas, Colorado, Kansas, Mississippi, Missouri and Texas who spoke to The Washington Post warned that the enormous cuts congressional Republicans are weighing could further destroy limited health-care access in rural America. Proposals to slash up to $880 billion over 10 years — which is expected to be accomplished largely by scaling back on Medicaid — would also impact those who do not rely on the programme but do rely on the medical facilities that are financially dependent on the programme’s reimbursements. Heart attack and stroke victims may lose crucial time being ferried by ambulance to big-city hospitals, healthcare experts say. Rural nursing homes may vanish, straining families in the poorest of regions. Those who are pregnant may have no choice but to drive long distances for prenatal checkups and to give birth. Read full story Source: Washington Post, 9 March 2025
  12. Content Article
    Despite recognition of the importance of patient and public involvement (PPI) in healthcare improvement, compelling examples of “what good looks like” for PPI in co-design of improvement efforts, how it might be done, and formalisation of methods and reporting are lacking. The authors of this study sought to address these gaps through a case study. The case study aimed to involve maternity service users in the co-design of clinical resources for a maternity improvement programme, using a four-stage approach: 1) establishing guiding principles for PPI in the pro gramme, 2) structuring PPI for the programme, 3) co-designing improvements with PPI, and 4) seeking feedback on PPI in the co-design process. Partnership-focused frameworks and other literature on PPI and co-design informed the guiding principles. The structure included a five-member PPI group who provided continuous input, and an additional 15-member PPI group who met twice to discuss experiences of obstetric emergency. PPI in the co-design processes shaped the development of the resources in multiple ways, such as strengthening the prominence given to listening to those in labour and their birth partners, ensuring inclusivity of visuals and language, and developing communication princi ples informing all resources. Feedback suggested that PPI members felt valued, listened to, and supported to provide unanticipated contributions. The case study demonstrated how a principled approach to PPI enabled service users to play a key role in co-design of clinical resources aimed at improving the quality and safety of maternity care in the UK. Further case studies, across different clinical areas and with varying levels of resources, are needed to validate this approach.
  13. News Article
    When doctors tried to work out whether Marie Tidball would need a specially designed birth plan, one asked her to lie fully clothed on the bed and spread her legs in the air so they could see how far they could open. The incident was one of several occasions when Tidball, now a Labour MP, felt neglected during her pregnancy and early motherhood because of the NHS’s failure to adapt on account of her physical disabilities. Tidball has physical impairments affecting all four of her limbs and had major surgeries on both her hips and legs as a child. She is speaking publicly about her experiences for the first time to highlight a report showing that disabled mothers and their children have significantly worse neonatal and postnatal NHS care than others. Speaking about the doctor’s request to open her legs, Tidball told the Guardian: “I was shocked, really, that that was their approach, rather than actually looking properly at some of my medical history and the notes around my hips. “They didn’t think about how that orthopaedic surgery might interact with birth, but also [about] carrying the baby and the way the baby was lying in uterus. They just hadn’t really thought those intersections through.” Read full story Source: The Guardian, 5 March 2025 Related reading on the hub Diagnostic safety: accessibility and adaptations– a (un)reasonable adjustment?
  14. Content Article
    This blog tells the story of Sarah,* whose baby was stillborn due to negligent maternity care. Sarah also suffered from severe, permanent injuries in labour which led to her decision to leave the UK. Sarah was admitted to a leading London maternity unit, but staff failed to recognise that she was in active labour. Lack of appropriate care and monitoring led to her baby dying in the womb. Once her baby's death had been confirmed, Sarah was then left to deliver without support for seven hours, which left her with permanent injuries. The article describes the findings of the trust's internal investigation and the negligence claim Sarah and her partner are pursuing. *not her real name
  15. News Article
    A midwifery boss has admitted that she repeatedly failed to inform the health watchdog about issues which contributed to a newborn baby's death. Ida Lock was born at the Royal Lancaster Infirmary (RLI) on the morning of November 9 in 2019 in a "poor condition" and with the umbilical cord wrapped around her neck. Ida's mum Sarah Robinson, from Morecambe, had gone to the hospital's central delivery suite at 7.30am after her waters broke the previous day. Sarah, who was 40+1 weeks pregnant, had previously attended the hospital after noticing reduced foetal movements. Despite midwife Lisa McGrow noticing that the baby's heartrate had dropped to 100bpm, below the acceptable range of 110-160bpm, Sarah was allowed to enter the birthing pool. Less than 20 minutes later, after Ms McGrow and a more senior midwife, Amanda Sailor, called for assistance, a doctor arrived and immediately said "we need to get this baby out now". However, after Ida was delivered, not breathing, there was a period of three and-a-half minutes when Mrs Sailor and delivery suite coordinator Celia Sykes were carrying out "ineffective" CPR. When Dr Matthew Phillips came into the room he ensured that Ida was properly resuscitated. Ida was transferred to the neonatal intensive care unit at the Royal Preston Hospital. Her parents were informed that she had suffered a severe brain injury, due to a lack of oxygen, and she sadly died seven days later. The inquest started earlier this month and on the 25 February heard from Carol Carlile who, in 2019, was the head of midwifery at the University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) which runs the RLI. Ms Carlile explained that she had been appointed by the trust to oversee the implementation of the 18 recommendations made following the publication of the Kirkup Report in 2015. Dr Bill Kirkup CBE had overseen a public inquiry into maternity services at UHMBT after the deaths of 11 babies and one mother. The inquest heard that Ms Carlile had "signed off" a Root Cause Analysis into Ida's death, carried out by the trust contrary to Care Quality Commission guidance. The report published following that analysis, and 'signed off' by Ms Carlile, concluded that "everything went well" with Ida's birth. Just a few weeks later the independent Healthcare Safety Investigation Branch (HSIB) published its own findings which highlighted several failings which it found contributed to Ida's death. Ms Carlile had no explanation as to why, despite there being six separate 'codes' which would have required her to report Ida's case to the Care Quality Commission, she had failed to do so and said: "I can't recall why I didn't do that. I should have done." Read full story Source: Lancs Live, 26 February 2025
  16. News Article
    A trust whose maternity care is under scrutiny had neonatal mortality rates nearly twice the average of similar units in 2023, new audit figures reveal. Leeds Teaching Hospitals Trust — which runs a high level (Level 3) neonatal intensive care unit, with neonatal surgery — has had higher than average adjusted death rates since 2017, the first year recorded by the MBRRACE-UK audit. But they have risen sharply in both 2022 and 2023, while the national rate has remained steady. The 2023 figures, published this month, give LTH’s neonatal mortality rate as 5.01 per 1,000 live births in 2023, compared to a group average of 2.6 for the total 26 UK providers with a level 3 NICU and neonatal. Last month the BBC reported the trust had information suggesting the deaths of at least 56 babies and two mothers during the past five years could have been prevented. Fiona Winser-Ramm and Dan Ramm, whose first baby Aliona Grace died at Leeds shortly after her birth in 2020, said the new MBRRACE data reinforced their demands for a local inquiry into LTH maternity services. Mr Ramm said: “They now look like an outlier. That figure of 5.01 is 92 per cent higher than the average of the comparator group. It is almost a scandal hiding in plain sight.” Read full story (paywalled) Source: HSJ, 24 February 2025
  17. News Article
    Poorer families are being denied millions of pounds in compensation from the NHS for maternity care failings compared with wealthier families, The Independent can reveal. Families whose babies experience brain damage due to negligent maternity care can receive multimillion-pound payouts to cover costs relating to the child’s future care and accommodation, based on their medical need. But a separate element covering the child’s predicted “loss of future earnings” is calculated on the basis of their family’s existing income and education levels, meaning that more affluent families get more cash. Critics have condemned the system as “unfair”, highlighting the fact that it gives the least financial support to the families who “need it the most”, and have called for earnings payments to be linked to the average wage. Two-thirds of NHS spending on compensation cases goes on maternity claims, according to NHS Resolution, the body that deals with compensation awards. Payouts for maternity negligence cost the taxpayer £2.6bn in 2022-23, the latest figures show, with the total cost of harm, including loss of earnings, valued at £6.6bn. Both figures were up on the previous year. The Medical Defence Union (MDU), which represents doctors in negligence cases, has described the system as “flawed”. It believes loss of earnings payments should be capped at three times the average wage, annually – and that “parental education, earnings or wealth should play no part in the assessment of damages awarded to minors”. Read full story Source: The Independent, 22 February 2025
  18. News Article
    More than 250 people have come together in a Facebook group to share stories of issues they have experienced with maternity care. All of the women were treated at Oxford's John Radcliffe (JR) Hospital, which is run by Oxford University Hospitals NHS Foundation Trust (OUH). Among them is Oria Malik, who told the BBC that following a "tough" labour her aftercare was "humiliating" and left her feeling "very vulnerable". Ms Malik gave birth at the JR seven months ago, and said what began as a positive experience "quickly turned" after her pain levels were ignored. "I just felt really isolated because I couldn't communicate to anyone how much pain I was in," Ms Malik said. "I told the midwife that I felt the need to push at 7am, and she said 'oh no, you're not in labour, you're fine' - but my body needed to push a baby out at that point." While inserting a cannula into Ms Malik's arm following the birth, one nurse was "so rough" with her hand that she "ended up with a blood clot" in her vein that has "still not really healed". Separately, Ms Malik said a maternity support worker consistently left the curtain open to her space on the ward. She said: "There were people and families in the bed's opposite who could see me laying in a bed - I didn't have any clothes on." "There was no privacy - I found it really humiliating and [it made me feel] very vulnerable." Read full story Source: BBC News, 24 February 2025
  19. News Article
    Losing Ben at the age of eight weeks in the paediatric intensive care unit of the Bristol Royal hospital for children in the spring of 2015 was traumatic and heartbreaking for Jenny and Allyn Condon. In the 10 years since, they say their pain has not eased but, if anything, has been made more acute by the way they have been treated by a health trust as they campaigned to find out why Ben died. “It has destroyed me,” said Jenny, who tried to kill herself and has post-traumatic stress syndrome. “I’m a broken woman. I’m in constant fight or flight.” Speaking at the end of a two-week inquest that concluded on Friday – which laid bare failings in Ben’s care and was often contradictory, complex and, as his parents see it, adversarial – Allyn said their precious memories of Ben had been taken away by the approach of the trust that runs the hospital. Ben was born prematurely on 17 February 2015. In April, he developed breathing difficulties and was taken to the children’s hospital, where doctors diagnosed human metapneumovirus (hMPV), a respiratory infection. He declined rapidly, had two cardiac arrests on 17 April and died. The Condons were immediately told that no postmortem examination was needed as the cause of death was straightforward. Doctors recorded acute respiratory distress syndrome (ARDS), hMPV and prematurity on his death certificate and his body was cremated. But several weeks after Ben died his parents were told that he also had a bacterial infection. A first inquest, in 2016, concluded that two respiratory illnesses and prematurity caused Ben’s death, but the next year, after the Condons continued to press, the University Hospitals Bristol and Weston NHS Foundation Trust admitted that a failure to give him antibiotics in a timely manner for the bacterial infection contributed to his death. In 2021, the NHS ombudsman said Ben died after “a catalogue of failings” in his treatment and there was an attempt to “deceive” his parents. The high court quashed the conclusions of the first inquest and a new inquest has taken place at Avon coroner’s court near Bristol. On Friday, the coroner who has heard the second inquest, Robert Sowersby, backed the Condons’ belief that the death certificate and conclusion of the first inquest were incomplete. Sowersby, the assistant coroner for Avon, stated that between 14 and 16 April consultants decided not to give Ben antibiotics. Sowersby said: “I find Ben should have been given antibiotics by 16 April at the latest,” and added that if he had been given antibiotics it would have stopped the pseudomonas infection entering his bloodstream. The coroner said some medics had a “patronising approach” to Ben’s parents and that Jenny and Allyn were not told what was going on or why and were not involved in important decisions. He said it was “hard” to understand a delay in telling them how sick Ben was. Sowersby said: “A lot of mistakes were made. The actions of various employees who were involved in Ben’s care or in subsequent investigations understandably aroused suspicion and contributed to the family’s inability to believe anything they were being told.” Read full story Source: The Guardian, 21 February 2025
  20. Content Article
    Understanding the effects of Covid-19 infection and vaccination during pregnancy can help inform clinical guidance and overcome concerns about vaccine safety. This study examined relationships between Covid-19 infection during pregnancy, Covid-19 vaccination during pregnancy and early child developmental concerns in children aged 13–15 months in Scotland. The study found that Covid-19 infections during pregnancy do not appear to be linked to early childhood developmental concerns and vaccinations during pregnancy appear to be safe from the perspective of early childhood developmental concerns. As some developmental concerns do not become apparent until children are older than 13–15 months, the authors recommended that future research continue to monitor outcomes as children grow and develop. You will need to sign up for a free Lancet account to view this article.
  21. News Article
    On 20 January, USAID issued a blanket “stop-work” order to all of its partners, demanding that organisations cease operations. In early February, the Trump administration fired the majority of all 10,000-plus USAID workers, leaving around just 290 employees. Though a US federal judge issued a temporary order to lift the aid freeze on 14 February, there is no clear evidence yet that programmes are back in action, with many hesitant to act under rapidly changing guidance. USAID’s reach across the world cannot be overstated. Some 141 countries relied on some form of USAID in 2024, worth $42.5bn (£33.3bn) in 2023 (the last available year). Around $600m each year of USAID funding has been spent on family planning; and now, the impact of its withdrawal is being felt worldwide. For every week without USAID, nearly one million women and girls worldwide are denied contraceptive care, according to analysis from the Guttmacher Institute, a leading reproductive health policy organisation. An average of 130,390 women received contraceptive care each day from US-funded programmes before the freeze. As a result of the immediate stop-work order, some 912,730 women will not receive contraception each week; amounting to approximately 3.8 million women who are estimated to have already been denied contraceptive care since the freeze (between 20 January and 18 February). Most of these programmes are in sub-Saharan Africa, with funding going to family planning in Mali, Niger, South Sudan, Ethiopia, and more. But the withdrawal of USAID will impact all sectors of global health; not least maternal health, where USAID has been vital to healthcare infrastructure in many of these countries. “Looking at the wider landscape in addition to family planning, when you take away maternal health services as well, which is what’s happening, there’s a cascading effect,” a USAID official explained. With gaps in midwives, equipment, and pre- and post-natal care, the risk of maternal death is likely to increase, in addition to pregnancy complications. Read full story Source: The Independent, 18 February 2025
  22. Content Article
    PROMPT (Practical Obstetric Multi-Professional Training) is an evidence-based training package for local maternity staff, previously associated with improvements in maternal and neonatal outcomes, reduction in litigation related to preventable harm and improved safety culture. PROMPT has previously been disseminated internationally using a train-the-trainer model. However, this has been associated with variations in uptake, fidelity and impact. In Wales, the project was supported by Welsh Government, and a structured scaling plan was developed, encompassing ongoing implementation support from a multi-professional team. This study describes the approach and process measures for national scaling of PROMPT across 12 obstetric-led maternity units in Wales.
  23. News Article
    An acute trust has been fined £1.7m — one of the largest penalties to date — after multiple failings in connection with the deaths of three babies under its care. Nottingham University Hospital Trust admitted failings in the care of the babies and their mothers on Monday, in the prosecution brought by the Care Quality Commission. Adele O’Sullivan, Kahlani Rawson and Quinn Parker all died shortly after being born in 2021 within the same short period of time. It is the largest fine for a trust from a CQC prosecution over maternity failings, although similar penalties have been issued for other care failures. According to BBC reporting, Nottingham Magistrates’ Court heard the fine was reduced from an initial £5.5m, and district judge Grace Leong accepted the defence’s request that the fine be payable in two halves, one half by 31 March 2026 and the second half by 31 March 2027. NUH has already been fined £800,000 after admitting failings in the care of Wynter Andrews, who died in 2019, which was only the second time the regulator has brought a case against an NHS maternity service, and the highest fine ever given for failings of this nature. The trust is also at the centre of the NHS’s largest ever maternity investigation, which is ongoing and expected to cover around 2,500 cases. Read full story Source: HSJ, 12 February 2025
  24. Event
    until
    Anna Davies will be looking at key themes from the Darzi review and the potential impact on the future of primary care and maternity services, including: A summary of the review findings Primary care services: the “shift” to community based care Access to quality maternity services Repairing the NHS – a return to peak performance. Anna Davies is a specialist health partner at Bevan Brittan and has extensive experience in respect of NHS governance and commissioning arrangements. Register
  25. News Article
    The mother of a week-old baby girl who died said she was made to feel her daughter's death was her fault. Sarah Robinson said that after the birth of her daughter Ida Lock at the Royal Lancaster Infirmary in 2019, she had been asked by staff if she had smoked. Lifelong non-smoker Ms Robinson told an inquest at Lancashire Coroners Court that a midwife had asked her if she was "sure" she had never smoked, because her placenta looked "gritty and fatty". But an independent investigation found there had been several problems during her delivery, and last year the hospital accepted there had been some failings. In 2015, an independent review into maternity care at the University Hospitals of Morecambe Bay NHS Trust - which runs the Royal Lancaster Infirmary - found that 11 babies and one mother had died in preventable circumstance between 2004 and 2013. The inquest heard Ms Lock had spent months questioning what she had done wrong following Ida's death. After pushing the Lancaster Royal Infirmary for a full explanation about what had happened, the couple were offered a meeting on 27 December 2019. They said they were ushered into a room off a ward, handed a number of medical records and left to go through them. "The message from that meeting was that Ida was very poorly when she was born. "I fell into a vicious circle, constantly questioning whether I was the reason that my daughter had died, and what had I missed," Ms Robinson said. In the spring of 2020, the couple received the outcome of a Healthcare Safety Investigation Branch (HSIB) inquiry, which had found significant failings in Ida's delivery. But an investigation the trust had completed – which the family were not involved in despite asking to be – found no failures, instead describing teamwork and record keeping as "outstanding". The couple told the inquest they had to battle the trust to understand what had happened. Read full story Source: BBC News, 10 February 2025

© 2025 Patient Safety Learning. All rights reserved.

Patient Safety Learning is registered as a charity with the Charity Commission Registration number 1180689.

×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.