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Found 810 results
  1. Content Article
    Prisons and Probation Ombudsman (PPO) Sue McAllister has published the independent investigation into the death of a baby (Baby B) at HMP Styal on 18 June 2020. The PPO was concerned that there were missed opportunities to identify the urgent clinical attention that Ms B, the baby’s mother, needed during that evening. The investigation found gaps in prison nurse training about reproductive health, long-acting reversible contraception and recognition of early labour, and the PPO has made recommendations to remedy these issues in all women’s prisons. View the report
  2. Content Article
    Do all your staff receive training for the management of anaphylaxis as part of their mandatory training? Do you have a specific maternal cardiac arrest emergency call to include obstetricians and neonatologists? Do all resuscitation trolleys in your trust have a scalpel and umbilical cord clamps as an essential kit requirement? Are you aware of the obstetric cardiac arrest quick reference guide from the Resus Council, OAA and MBRRACE? Obstetric cardiac arrest is rare but devastating. This quick reference guidance, produced by Resuscitation Council UK and Obstetric Anaesthetists’ Association (and endorsed by MBRRACE), has been developed to aid Advanced Life Support providers response to this. It aims to help structure the team response, with reminders of modifications required for the pregnant patient and causes of cardiac arrest to consider.
  3. Content Article
    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to help improve patient safety in relation to the instructions 999 call handlers give to women and pregnant people who are waiting for an ambulance because of an emergency during their pregnancy. The HSIB investigation reviewed the case of Amy, who was 39 weeks and 4 days pregnant with her first child. She contacted 999 after experiencing abdominal cramps and bleeding. While waiting for an ambulance to arrive, Amy received pre-arrival instructions which were generated through a clinical decision support system (CDSS) from a non-clinical call handler. Amy was then taken by ambulance to hospital where her baby, Benjamin, was delivered by emergency caesarean section. Amy had excessive blood loss due to a placental abruption and was admitted to the high dependency unit for 12 hours following the birth. Benjamin required resuscitation to help him breathe on his own, he was intubated, and he received 72 hours of therapeutic cooling. He spent 13 days in hospital.
  4. Content Article
    The Healthcare Safety Investigation Branch (HSIB) carried out a themed review of their maternal death investigations during the coronavirus (COVID-19) pandemic. The national learning reports can be used by healthcare leaders, policymakers, and the public to: Aid their knowledge of systemic patient safety risks. Understand the underlying contributing factors. Inform decision making to improve patient safety. Explore wider patient safety processes.
  5. Content Article
    Black and Asian bereaved parents whose baby died during pregnancy or shortly after birth have shared their experiences as part of the Sands Listening Project. The 56 parents who took part shone a light on care that works well, while also highlighting barriers, biases, and poor care. In the report, published by Sands, you can read more about: the findings pregnancy loss and baby deaths among Black and Asian babies in the UK real-life experiences and case studies what needs to change. Follow the link below to access the Listening Project report on the Sands website. 
  6. Content Article
    This guide aims to help staff and services understand the impact of psychological trauma on women in the perinatal period and respond in a sensitive and compassionate way. It aims to support staff to ensure they ‘do no harm’ through care delivery that, without thought or intention, could retraumatise individuals. This includes examples of how to: recognise and understand the impact of psychological trauma and how experiences may present during the perinatal period respond to disclosures and tailor care to needs of women and families so that services do not retraumatise individuals best support staff working in maternity and mental health services, acknowledging the effects of vicarious trauma and that staff may have their own experiences of trauma, which could impact on their capacity to deliver trauma-informed care.
  7. Content Article
    From early on in the COVID-19 pandemic, the Maternal Mental Health Alliance (MMHA) and Centre for Mental Health were concerned about the increased mental health challenges that women during and after pregnancy were likely facing as a result of the pandemic and government-imposed restrictions introduced to tackle it. Thanks to Comic Relief ‘Covid Recovery’ funding, the MMHA commissioned the Centre to explore just how much of a challenge the pandemic has placed on perinatal mental health and the services that support women, their partners, and families during this time. This report draws together all of the available data collected during the pandemic for the first time.
  8. Content Article
    This national learning report from the Healthcare Safety Investigation Branch (HSIB) will highlight the themes emerging from their contact with families during their patient safety investigations. It is due to be published in spring 2020. HSIB's national learning reports describe common themes and findings that come out of their national investigation programme and their maternity investigation programme. The information in these reports is used to inform future HSIB investigations or programmes of work.
  9. Content Article
    Children born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. As such, it is vital that women and girls are dispensed valproate safely. The General Pharmaceutical Council is reminding all pharmacy professionals of what they must do to ensure women and girls receive the right information about valproate and the risk of birth defects. The update includes
  10. Content Article
    Following Jeremy Hunt’s appointment as chancellor, HSJ is now hosting the Patient Safety Watch newsletter, written by Patient Safety Watch trustee James Titcombe.  Read the latest newsletter: Patient Safety Watch: What can be done to improve duty of candour?
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