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News Article
Hospitals prosecuted over baby deaths
Patient Safety Learning posted a news article in News
The trust at the centre of a maternity investigation is to be prosecuted by the Care Quality Commission over the deaths of three babies. Nottingham University Hospitals Trust intends to plead guilty to the charges relating to care and treatment to the babies, it has said. The trust is at the centre of the NHS’s largest ever maternity investigations, which is expected to cover around 2,500 cases. It has already been fined £800,000 after admitting failings in the care of Wynter Andrews, who died in 2019. In a statement, the trust said: “We can confirm that the CQC is bringing charges against Nottingham University Hospitals Trust following an investigation into three deaths which occurred in our maternity services in 2021. “We have co-operated with the CQC throughout their investigation, and intend to plead guilty to the charges when proceedings open. “We are not able to comment any further at this stage.” Read full story (paywalled) Source: HSJ, 7 February 2025 -
Content Article
PHSO: Prioritising patient safety (Winter 2025)
Patient Safety Learning posted an article in PHSO investigations
Prioritising patient safety is a new quarterly blog series from the Parliamentary Health and Service Ombudsman (PHSO). Each month, PHSO publishes between 70 to 100 of their casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again. Through these blog, Tony Dysart, Senior Lead Clinician, will be highlighting some of the cases PHSO publish to share good practice and findings from the casework more widely. This first blog focuses on two cases PHSO have looked into about maternity care and imaging. -
Content ArticleSuboptimal intrapartum electronic fetal heart rate monitoring using cardiotocography has remained a persistent problem (EFM-CTG). This study aimed to identify the range of influences on the safety of using EFM-CTG in practice. The authors looked at 142 articles and 14 reports and identified influences on EFM practice across all 19 domains of the contributory factors framework, including those relating to cognitive, social and organisational factors and interactions between professional work and tools used for fetal monitoring. They concluded that to reduce avoidable harm associated with electronic fetal monitoring a systems approach is required based on a sound understanding of the full range of influences on practice.
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Content ArticleFindings from the MBRRACE report on maternal deaths (2022) highlight increasing inequalities in maternal care, impacting women in deprived and disadvantaged areas. Addressing the broader physical and mental health of mothers, and understanding social determinants, are essential to closing this gap. This video series from the Royal College of Obstetricians and Gynaecologists (RCOG) discusses what actions are required to understand and work with vulnerable women and determine the best way to care for women who require complex intersecting services. Understanding the scale of the problem – setting the scene for action The impact of COVID-19 on service provision and maternal and neonatal outcomes: through the lens of inequalities Intimate partner violence: Pregnancy as a time to identify high-risk women and prevent long-term consequences NHS England's Maternity and neonatal equity & equality programme Children's social care contact Models of care for women with social risk factors – Project 20 Suffolk and North East Essex ICB Smokefree Pregnant Households Pathway It's ok to ask in maternity What evidence do we have for effective interventions Q&A session
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Content ArticleLaura Abbott and colleagues highlight gaps in clinical care for pregnant women in prison and consider how best to meet their needs.
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News Article
Deaths of 56 babies at Leeds hospitals may have been preventable
Patient Safety Learning posted a news article in News
The deaths of at least 56 babies, and two mothers, at an NHS trust over the past five years may have been prevented, the BBC has found. The two maternity units at the Leeds Teaching Hospitals (LTH) NHS Trust are rated "good" by England's healthcare regulator, but two whistleblowers have told the BBC they believe the units are unsafe. Bereaved parents say they are concerned that the trust's chief executive during the period most of the deaths occurred is now leading the regulator, saying this could affect its independence in investigating LTH Trust. In a statement, the trust told the BBC the vast majority of births at Leeds were safe, and deaths of mothers and babies were fortunately very rare. It added that Leeds cares for a higher volume of babies with complex conditions as it is one of a "handful of specialist centres" in the UK. The families describe a "tick box" and "wait and see" culture at the trust, plus a lack of compassionate care. This has been echoed by whistleblower Lisa Elliott, who worked at the two sites in 2023. Describing the care as "appalling", she highlighted a failure to listen to patients. "That's when disasters happen, and a lot of them can be avoided," she said. Read full story Source: BBC News, 17 January 2025 -
Content ArticleTo help women / birthing people have a safe and healthy birth there are national and local healthcare guidelines. However, from time to time, people may choose to give birth outside of these guidelines. Based on findings from MNSI investigations, this paper explores how healthcare professionals can support people who choose to give birth outside of guidance and what we can learn. What can maternity providers do? Maternity providers can discuss and explore with their teams what support is available when someone decides to give birth outside of guidance. These ‘safety prompts’ will help facilitate those conversations. Safety prompts Do you have a guideline or process to support staff and mothers / birthing people when care choices are outside of national or local guidance? Is there any training available for staff in how to navigate conversations in order to facilitate supported decision making? Can women / birthing people benefit from birth choice clinics that are multi professional and use supported decision-making principles? When a woman / birthing person requests a birth plan that deviates from national or local guidance, is this agreed in advance of birth? Do discussions include contingencies so there are clear parameters for acceptable care pathways when the situation changes, or an emergency occurs? Are there resources (leaflets/videos/infographics) available that include up to date information, that are easily accessible and clear, to assist mothers / birthing people in supported decision-making when seeking care outside of national or local guidance? Have you considered exploring with families their reasons for choosing to birth outside of guidance to enable learning?
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EventuntilThe 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 a standardised, system focused methodology, into maternity events, including 237 maternal deaths. Pulmonary embolism (PE) remains one of the leading causes of direct maternal deaths in the UK, resulting in 1.5 deaths per 100,000 maternities from 2019-2020. This webinar will explore the findings from MNSI's investigation into maternal deaths following pulmonary embolism. Speakers: Dr Charlotte Frise Dr Louise Page Stephanie Smith Register for the webinar
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EventuntilThe 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. This webinar will explore the findings from MNSI's investigations into first trimester deaths in England from venous thromboembolism associated with hyperemesis. Speakers: Dr Charlotte Frise Dr Louise Page Chandrima Biswas Kirsty MacLennan Register for the webinar
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News ArticleThe father of a seven-week-old boy who died after being breastfed in a baby carrier is calling for increased safety standards around baby slings. James Alderman, who was known as Jimmy, was being breastfed "hands-free" within a baby carrier worn by his mother while she moved around their home. Jimmy's father, George Alderman, told Sky News: "Baby slings are sold as being a lifesaver, allowing you to get on with your business while your baby's safe and close to you, but in this instance, we had our baby close, but not safe." The inquest into his death heard Jimmy was in an unsafe position too far down the sling. Mr Alderman said that while much of the available advice around slings focused on them not being too tight, few people were aware of the danger of the sling not being tight enough, and so allowing the baby to slump. Explaining what medical experts think happened to Jimmy, he said: "After he'd been feeding, he fell asleep and then he slumped forwards. Then, because his head was covered and he had his chin against his chest, he was facing downwards. "Nothing was covering his face, but because of the position he was in, that meant that not enough oxygen was going into his lungs because he was small and not fully developed, and that's why he stopped breathing." Mr Alderman said that while many brands of baby carriers said they were safe for breastfeeding, the lack of advice around how to safely do it meant that parents were "left to work it out by themselves". Read full story Source: Sky News, 30 December 2024
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Content ArticleBaby Jimmy was being breastfed within a baby carrier worn by his mother. After 5 minutes she found that he was collapsed and although immediate resuscitation was commenced he died 3 days later on 11 October 2023 in St George’s Hospital. Jimmy died because his airway was occluded as he was not held in a safe position while within the sling. There is insufficient information available from any source to inform parents of safe positioning of young babies within carriers and in particular in relation to breastfeeding. It was accepted that the sling was being worn snugly, not tightly, and although she could see his face when she looked down, the TICKS acronym was not met by his position within the sling as Jimmy was too far down. The TICKS acronym was prepared by the (now disbanded) UK consortium of sling retailers and manufacturers tight in view at all times close enough to kiss keep chin off the chest supported back. There appeared to be no advice in the literature regarding the risk of baby slumping and the risk therefore of suffocation, particularly if baby is under the age of 4 months, and no advice that breastfeeding “hands free” a young baby is unsafe, due to the risk of suffocation and not being able to meet every aspect of TICKS. There appeared to be no helpful visual images of “safe” versus “unsafe” sling/carrier postures. Evidence was given by the witnesses assisting the inquest that public information, readily available, not too complex but consistent in message would be welcomed to advise and instruct. Matters of concern There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings This is notwithstanding a significant increase over recent years in the use of such equipment. The question of whether it is safe to breastfeed “hands free” is not addressed or referred to in the public domain or manufacturers literature. The NHS available literature provides no guidance or advice. The only current “tips” are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful Young babies are at risk of suffocation. Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
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Content ArticleThis Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents trend statistics on severe maternal morbidity (SMM) overall and for groups of SMM complications by patient characteristics. Key findings From 2016 to 2021, the rate of severe maternal morbidity (SMM) increased 40 percent, from 72.0 to 101.1 per 10,000 delivery stays. Patients with the largest increase in the SMM rate from 2016 to 2021 include: Women of Asian/Pacific Islander non Hispanic race and ethnicity (56 percent) Women with self-pay/no charge as the expected payer (48 percent) Women aged 12–19 and 20–24 years (44 percent) Women living in middle community level income areas (43 percent) Women living in large metro areas (42 percent) Delivery stays with respiratory complications (137 percent) followed by renal complications (119 percent) and sepsis (54 percent) had the largest six year rate increase compared with all other complications. Although the SMM rates increased between 2016 and 2021 for women of all ethnicities, the increase was largest for women who were Other, non-Hispanic (48 percent), Black non-Hispanic, and Hispanic (43 percent for both), as compared to women who were White, non-Hispanic (34 percent).
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News ArticleA woman died soon after the birth of her fifth child due to "basic failures" in her care, a report said. Laura-Jane Seaman, 36, died at Broomfield Hospital, Chelmsford, Essex, on 23 December 2022 following a significant peritoneal haemorrhage. A prevention of future deaths report by a coroner said the bleeding was not identified, despite Ms Seaman's repeated concerns that she was "gushing" - and her appeals to staff to "not let me die". Ms Seaman had been admitted to the hospital on 21 December and while the birth of her baby was uneventful, she subsequently suffered a haemorrhage that was not noticed by staff for hours - despite her having a known history of haemorrhages. Earlier this year, a coroner had found multiple "gross failures" by healthcare professionals and said if these had not occurred, Ms Seaman, from Witham, would not have died. Read full story Source: The Guardian, 24 December 2024
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Content ArticleIt is widely agreed that collaboration with people with lived experience of specific health conditions or health services is both a moral imperative and improves research quality, validity and impact. However, there is little agreement about how to practise public involvement. This article describes the formation and work of the Nottingham Maternity Research Network, an ongoing research reference panel that supports public involvement in maternal health research. Drawing on nine years’ experience, researchers and public contributors reflect together on the key issues to consider when co-producing research with maternity service users: first, pragmatic considerations, and second, creating a safe space for drawing on intimate and sometimes traumatic experiences. The authors argue that a sustained model of public involvement and engagement—that is, a standing group rather than a series of project-based, time-limited opportunities for involvement—brings opportunities to build trust and to develop a community that is supportive and inclusive. However, the sustained model of public involvement also brings practical challenges.
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Content ArticleThe Maternal, Newborn and Infant Clinical Outcome Review Programme has published an MBRRACE-UK Perinatal Confidential Enquiry report on the care of recent migrant women with language barriers who have experienced a stillbirth or neonatal death. Looking at the care of 25 women and their babies, this report found that services did not meet the needs of these women effectively. Other key findings include: 96% of the women had a documented need for an interpreter, however, only 27% took place with a documented professional interpreter over 589 separate contacts with healthcare services. 68% of women didn’t book their pregnancy, or booked late in their pregnancy, highlighting gaps in antenatal care. Only 51% of women whose baby died received documented bereavement care in the community. There was a lack of research to inform service development for women new to the UK and non-English speakers. Recommendations In addition to stating the continued relevance of previous recommendations, this report contains five new recommendations for improvement: Ensure that the number of women who require language support, and the support provided at each visit, is recorded systematically. This includes documenting the use of professional interpreting services at clinical care interactions and when supporting women through the navigation of care pathways, as well as recording when these services are not available. The resulting data should be used to implement quality improvement measures, and be assessed against existing NICE guidance. Ensure services provide advocacy for women who have been in the UK for less than a year, or do not speak or understand English, to support care navigation. This should incorporate midwifery and obstetric care when indicated. Support research to understand women’s and healthcare professionals’ views on the barriers and facilitators to accessing and navigating maternity and neonatal care for women who have been in the UK for less than a year, or do not speak or understand English and require professional interpreting services. Use the findings to co-design services. Pilot the provision of an initial assessment appointment for migrant women of childbearing age when they first access health care services. The purpose would be to carry out a holistic assessment of their reproductive healthcare needs, provide information about reproductive health and availability of maternity services, and to understand any concerns they may have about accessing healthcare services. Develop provision for multiple routes of access to maternity care. These routes should include the ability for a health or social care professional, in any setting, to make a direct referral to maternity services on behalf of a woman with her consent.
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News ArticleThe NHS is forced to spend a “staggering” £14.7bn a year treating people who have been harmed by mistakes made during their care, a report reveals. And a stark north/south divide on patient safety has opened up across England, with double the amount of death and disability caused by medical negligence in the north-east than in London. The report, by experts at Imperial College London, found that the safety of the care patients receive had declined over the past two years. The authors include Prof Lord Ara Darzi, the surgeon and former health minister who produced a major NHS report for the Labour government, which highlighted avoidable patient deaths. Darzi said there had been “alarming declines” in 12 key metrics of patient safety in England since 2022. They include maternity care, in which there are growing rates of stillbirth, babies dying during or soon after they are born and also women dying while giving birth. “Our analysis highlights a troubling increase in neonatal and maternal deaths, with Black women disproportionately affected,” said Darzi, the co-director of Imperial’s Institute of Global Health Innovation, which drew up the report. He urged ministers and NHS bosses to take “immediate action” to improve maternity care. The Royal College of Midwives said staff shortages, including of specialist midwives, were a key reason for the recent deterioration in women’s experiences during pregnancy, labour and afterwards – a decline which reviews by other organisations have also identified. Read full story Source: The Guardian, 12 December 2024
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Content ArticleThis report presents the national state of patient safety in England in 2024. Two years on from their first report, the authors provide an updated analysis of the publicly available data. The report concludes that performance in key areas such as maternity care has deteriorated, requiring urgent attention. This report was produced by Imperial College London's Institute of Global Health Innovation in partnership with the charity Patient Safety Watch. Key figures highlighted in this report include: In 2023, the number of deaths that could have been avoided if the UK matched the top 10% of Organisation for Economic Co-operation and Development (OECD) countries was 13,495. In 2023, the UK ranked 21st out of 38 OECD countries for patient safety. Cost of harm for claims resulting from incidents in 2023/24 was £5.1 billion. Maternal deaths increased from 8.8 to 13.4 per 100,000 maternities between the 2017-2019 and 2020-2022 periods – an increase of 52.3%. In 2023, the proportion of patients who said there were enough nurses on duty to care for them was 56%. As of September 2024, the proportion of people waiting more than four hours for a treatment decision in A&E was 25%. In 2023, 65% of maternity units in England were rated as “inadequate” or “requires improvement” for safety by the Care Quality Commission. In June 2024, the number of people waiting for elective care was 7.6 million. 2 in 3 staff feel unable to carry out their jobs fully due to workforce shortages. The report sets out two recommendations to support the long-term improvement of patient safety in England: Local NHS organisations must be supported to adopt evidence-based interventions to tackle the most common safety problems causing significant harm to patients. The report’s analysis of trust patient safety plans identified six common problems that many organisations are tackling, such as pressure ulcers and patient falls. Adopting proven interventions to common problems like these would finally see the NHS truly acting like a National Health Service. The authors envisage a future where the first port of call for NHS organisations is a repository of such interventions, along with the support they need to implement them, rather than developing their own solutions from scratch. National organisations must agree on a focused set of patient safety improvement priorities for the system to rally around. The report’s analysis found a crowded landscape of patient safety bodies, an opaque process for national priority setting, and evidence that the system cannot keep pace with the volume of recommendations it receives. The authors envisage a future where patients and healthcare workers are partners in the development of these priorities, and where national organisations rationalise their own activities to ensure the NHS is supported to deliver improvements against them.
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News Article
Mothers came to harm at maternity unit says report
Patient Safety Learning posted a news article in News
Mothers and newborn babies came to harm because of staffing shortages and a "toxic" culture at Edinburgh's maternity unit, according to a whistleblowing investigation seen by BBC News. NHS Lothian commissioned a report into the obstetrics triage and assessment unit at Edinburgh Royal Infirmary after a member of staff raised concerns in February this year. The investigation upheld or partially upheld 17 concerns about safety. NHS Lothian said an "improvement plan" designed to enhance patient safety and improve the working environment for staff was already under way as a result of the report. The health board said a detailed review was taking place into the death in a bid to give the family much-needed answers. But staff say they fear the risks to patients remain. "We are afraid we can't provide safe patient care and that women and babies are being harmed," one staff member said, speaking to the BBC anonymously. "The situation has been getting worse over the past five years and it is at its worst now." Read full story Source: BBC News, 10 December 2024 -
Content ArticleBlack Maternity Matters is a collaboration supporting perinatal staff to reduce the inequitable maternity outcomes faced by Black mothers and their babies. Through a ground-breaking programme of training, including anti-racist education, peer support, and quality improvement, it supports maternity systems to provide safer, equitable care. In a recent episode of the Leading Improvement in Health and Care podcast, Penny Pereira, Q Managing Director, spoke to three improvement leaders from the Black Maternity Matters programme.
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News Article
USA: Most rural hospitals have closed their maternity wards, study finds
Patient Safety Learning posted a news article in News
Over 500 hospitals in US have closed their labour and delivery departments since 2010, according to a large new study, leaving most rural hospitals and more than a third of urban hospitals without obstetric care. Those closures, the study found, were slightly offset by the opening of new units in about 130 hospitals. Even so, the share of hospitals without maternity wards increased every year, according to the study, published in JAMA.. Maternal deaths remained persistently high over that period, spiking during the pandemic. Because its data runs only through 2022, the study does not account for the additional challenges that hospitals have faced since the Supreme Court case that overturned Roe v. Wade that year and led many states to restrict abortion. States with abortion bans have experienced a sharp decline in their obstetrician work force. “We’re more than a decade into a severe maternal mortality crisis in the United States, and access to hospital-based maternity care has continued to decline over that entire time period,” said Katy Kozhimannil, the study’s lead author and a professor of health policy at the University of Minnesota. Read full story (paywalled) Source: The New York Times, 4 December 2024 -
Event
Black Maternal Health Conference 2025
Patient Safety Learning posted an event in Community Calendar
The 3rd annual Black Maternal Health Conference UK convenes healthcare providers, researchers, policymakers, advocates, midwives, doulas and mothers to address systemic challenges in maternal care. Through interactive sessions and open dialogue, we're creating pathways to equitable, dignified and culturally competent care. Register -
News ArticleMore than a third of pregnant women in England do not always get help from maternity staff during labour or childbirth, the NHS care regulator has found. Even more – almost half – do not always get help when they are in hospital after giving birth, a Care Quality Commission (CQC) survey of almost 19,000 women’s experiences of maternity care found. A significant minority of women do not have confidence in the staff who look after them when they are receiving antenatal care (30%), during their labour and birth (23%) and after they have delivered their child (31%), the research also shows. In addition, one in seven do not get the pain relief they feel they need during labour and birth and a quarter are unable to ask staff questions after their baby’s birth. The worrying findings underline the already acute concern about the quality of care provided by NHS maternity services in England, many of which the CQC has deemed to be unsafe. Read full story Source: The Guardian, 28 November 2024
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Content Article
This survey from the Care Quality Commission (CQC) looked at the experiences of pregnant women and new mothers who used NHS maternity services in 2024. Women who gave birth between 1 and 29 February 2024 (and during January if a trust did not have a minimum of 300 eligible births in February) were invited to participate. Fieldwork took place between May and August 2024, and responses were received from 18,951 people, The survey shows some areas of improvement over the past year, particularly regarding access to mental health support during pregnancy. However, there remain other aspects of maternity care where people report a poorer experience and where analysis indicates a longer term decline in positive feedback over time, including communication during labour and birth, information provided during care in hospital after birth and involvement in postnatal care. Positive results Antenatal care More women were asked about their mental health during antenatal check-ups (76% said they were ‘definitely’ asked compared with 75% in 2023). There has been steady improvement seen in this question area over the past five years. Eighty-nine per cent of people surveyed said they received mental health support as part of their antenatal care compared with 88% in 2023, and 85% in 2022. Most of those surveyed (83%) also said that their midwives ‘always’ listened to them, that they were ‘always’ spoken to in a way they could understand (88%), and they were ‘always’ involved in decisions about their antenatal care (80%). Labour and birth More people surveyed felt they were given appropriate information on the risks associated with an induced labour prior to being induced (74% in 2024 compared with 69% in 2023). Postnatal care Respondents reporting that their partner or someone else close to them was able to stay as much as they wanted in hospital after the birth increased from 56% in 2023 to 63% in 2024. Key areas for improvement Confidence and trust Fewer people said they ‘definitely’ had confidence and trust in the staff providing their antenatal care (70% in 2024 compared with 71% in 2023), during labour and birth (77% in 2024 compared with 78% in 2023) and postnatally (69% in 2024 compared with 72% in 2023). Communications and interactions with staff A quarter (25%) of respondents felt they did not have the opportunity to ask questions after their baby was born. Only 58% of people surveyed said they were ‘always’ given the information and explanations needed in hospital after birth (compared to 60% in 2023). Fewer people reported ‘always’ feeling listened to by staff providing postnatal care after leaving hospital (75% in 2024 compared with 77% in 2023). Availability of staff There has been a five-year downward trend in the number of people reporting that they were ‘always’ able to get help from staff during labour and birth (64% in 2024 and 72% in 2019) and in those who said they were ‘always’ spoken to by staff in a way they could understand (85% in 2024 and 90% in 2019). Just over half (60%) of people surveyed said they saw or spoke to a midwife as much as they wanted after the birth (down from 63% in 2023). -
News ArticleLoughborough University researchers have developed an artificial intelligence (AI) tool that identifies the key human factors influencing maternity care outcomes, supporting ongoing efforts to improve safety for mothers and babies. Developed by AI and data scientist Professor Georgina Cosma and human factors and complex systems expert Professor Patrick Waterson, the tool analyses maternity incident reports to highlight key human factors – such as communication, teamwork, and decision-making – that may have impacted care outcomes, providing insights into areas that could benefit from additional support. When an adverse maternity incident occurs in England, detailed investigation reports are produced to identify opportunities for learning and enhancing safety. Currently, experts must carry out manual reviews to extract human factor insights from incident reports. This process is resource-intensive, time-consuming, and relies on individual interpretation and expertise, which can lead to varying conclusions. The AI tool addresses these challenges by identifying and categorising human factors in reports quickly and consistently. Its standardised approach allows it to analyse multiple reports and identify recurring factors, helping pinpoint areas that would benefit most from additional support. The AI model was trained and tested on data from 188 real maternity incident reports. It successfully identified human factors in each report and analysed them collectively, providing insights into where extra support could improve outcomes. "AI has transformed our analysis of maternity safety reports. We've uncovered crucial insights far quicker than manual methods," said Professor Cosma. “This has enabled us to gather a comprehensive understanding of where there are areas for improvement in maternity care, and these insights can help identify ways to enhance patient safety and improve outcomes for mothers and babies." Read full story Source: Loughborough University, 20 November 2024
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Content ArticleMaternity care is a complex system involving treatments and interactions between patients, healthcare providers, and the care environment. To enhance patient safety and outcomes, it is crucial to understand the human factors (e.g. individuals' decisions, local facilities) influencing healthcare. However, most current tools for analysing healthcare data focus only on biomedical concepts (e.g. health conditions, procedures and tests), overlooking the importance of human factors. A new approach, called I-SIRch, uses artificial intelligence to automatically identify and label human factors concepts in maternity investigation reports describing adverse maternity incidents produced by England's Healthcare Safety Investigation Branch (HSIB). These incident investigation reports aim to identify opportunities for learning and improving maternal safety across the entire healthcare system. Unlike existing clinical annotation tools that extract solely biomedical insights, I-SIRch is uniquely designed to capture the socio-technical dimensions of patient safety incidents. This innovation enables a more comprehensive analysis of the complex systemic issues underlying adverse events in maternity care, providing insights that were previously difficult to obtain at scale. Importantly, I-SIRch employs a hybrid approach, incorporating human expertise to validate and refine the AI-generated annotations, ensuring the highest quality of analysis. Our work demonstrates the potential of using automated tools to identify human factors concepts in maternity incident investigation reports, rather than focusing solely on biomedical concepts. This approach opens up new possibilities for understanding the complex interplay between social, technical and organisational factors influencing maternal safety and population health outcomes. By taking a more comprehensive view of maternal healthcare delivery, we can develop targeted interventions to address disparities and improve maternal outcomes. Targeted interventions to address these disparities could include culturally sensitive risk assessment protocols, enhanced language support, and specialised training for healthcare providers on recognising and mitigating biases. These findings highlight the need for tailored approaches to improve equitable care delivery and outcomes in maternity services. The I-SIRch framework thus represents a significant advancement in our ability to extract actionable intelligence from healthcare incident reports, moving beyond traditional clinical factors to encompass the broader systemic issues that impact patient safety.
