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Found 804 results
  1. News Article
    Parents of babies who have died or been harmed as a result of poor care are demanding that ministers order a public inquiry into repeated failings in NHS maternity units. They want Steve Barclay, the health secretary, to set up a judge-led statutory inquiry to investigate recurring problems in maternity services, which cost the NHS in England £2.6bn a year in damages. Babies are still being damaged and dying, despite previous inquiries into maternity scandals at the Morecambe Bay, Shrewsbury and Telford, and East Kent NHS trusts recommending changes. The NHS’s failure to improve maternity safety is so alarming that a public inquiry is needed to finally ensure that women and babies no longer come to harm, the families say. The Maternity Safety Alliance, a group of relatives of newborns who have died due to lapses in NHS childbirth, warned that scandals will continue unless such an inquiry is held. “Our babies are too precious to keep on ignoring the reality that despite a raft of national initiatives and policies implemented in the wake of investigations and reports, systemic issues continue to adversely impact on the care of women and babies. “Far too much avoidable harm continues to devastate lives in circumstances that could and should be avoided. Fundamental reform is needed,” they said in a letter urging Barclay to intervene. Read full story Source: The Guardian, 31 October 2023
  2. News Article
    The parents of a baby boy who died at seven weeks old after a hospital did not give him a routine injection have described the failure as “beyond cruel”. William Moris-Patto was born in July 2020 at Addenbrooke’s hospital in Cambridge, where it was recorded in error that he had received a vitamin K injection – which is needed for blood clotting. The shot is routinely given to newborns to prevent a deficiency that can lead to bleeding. His parents, Naomi and Alexander Moris-Patto, 33-year-old scientists from Chatteris, Cambridgeshire, want to raise awareness about the importance of the vitamin after a coroner concluded William would not have died had the hospital administered the injection. On Friday, the coroner Lorna Skinner KC described the omission as “a gross failure in medical care amounting to neglect”. Alexander Moris-Patto, a researcher at the University of Cambridge who recently co-founded William Oak Diagnostics to test for deficiencies in babies, said: “What’s come out of the inquest for me is that the systems they [the trust] put in place to try to prevent this happening again are not satisfactory.” He stressed the importance of the vitamin K injection, adding that about 1% of the UK population opt out of it. “We want people to know more about it, to understand how critical it can be, and for hospitals to take seriously the responsibility they have in those first precious hours of a baby’s life,” he said. Read full story Source: The Guardian, 29 October 2023
  3. Content Article
    The Children and Young People’s Mental Health Coalition (CYPMHC) and the Maternal Mental Health Alliance have launched ‘The Maternal Mental Health Experiences of Young Mums’ report, which includes both a literature review and first-hand insights from young mums impacted by maternal mental health problems.
  4. News Article
    To new parents processing the shock of delivery and swimming in hormones, newborns can feel like a tiny, terrifying mystery; unexploded ordinance in a crib. “We were totally unprepared,” says Odilia. Neither she or her husband had ever changed a nappy and had no idea the baby needed feeding every three hours. “If you’re a new mum or dad, you have no idea,” recalls Anouk, a new mother. “I’m a doctor,” says Zarah, another new mother, incredulously. “So, you would expect that I’d know something, and I knew some things, but you really don’t have any clue.” The difference for these new parents, compared to the rest of us, is that they gave birth in the Netherlands. That meant help was instantly at hand in the form of the kraamzorg, or maternity carer. Everyone who gives birth in the Netherlands, regardless of their circumstances, has the legal right – covered by social insurance – to support from a maternity carer for the following week. These trained professionals come into your home daily, usually for eight days, providing advice, reassurance and practical help. It’s a different role to midwives, who continue to monitor women and babies after the birth in the Netherlands; the maternity carer updates the midwife on the mother and baby’s health and progress as well as supporting the parents as they come to terms with their new child. A maternity carer in the Netherlands, explains Betty de Vries of Kenniscentrum Kraamzorg, the organisation that registers maternity carers, “takes care of the woman the first week, advises her on breastfeeding and bottle feeding, hygiene, gives advice … everything to do with safe motherhood and a safe baby. She is there for the whole day most of the time so she can see how they are doing.” Her colleague, director Esther van der Zwan, adds: “It’s a lot of responsibility.” To prepare, maternity carers train for three years – a combination of academic and on-the-job placements – and have regular refresher training in everything from CPR to breastfeeding support.
  5. Content Article
    Reducing inequalities in maternal healthcare in England is an important policy aim. One part of achieving that is to ensure that women from Black, Asian and minority ethnic communities, as well as women from the most deprived areas, see the same midwife or midwifery team throughout their pregnancy and postnatal period. Emma Dodsworth takes a closer look at the data to reveal what progress is being made on this.
  6. News Article
    Almost two-thirds of maternity units provide dangerously substandard care that puts women and babies at risk, the NHS watchdog has said in a damning report. The Care Quality Commission (CQC) has rated 65% of maternity services in England as either “inadequate” or “requires improvement” for the safety of care – up from 54% last year. Services are beset by a host of problems, including serious staff shortages and internal tensions, which mean that too many mothers and their babies receive care that is not good enough, it said. Women too often face delays in accessing care, do not receive the one-to-one care from a midwife to which they are entitled or experience communication problems with staff looking after them, including being shouted at by midwives. The CQC judged overall quality of care to be inadequate or require improvement at 85 maternity units, almost as many at which it rated it to be either good or outstanding – 87. The number of units offering substandard care has soared by 30 in the last year, from 55 to 85. It said that, having inspected 73% of all maternity units, “the overarching picture is one of a service and staff under huge pressure. People have described staff going above and beyond for women and other people using maternity services and their families in the face of this pressure. “However, many are still not receiving the safe, high-quality care that they deserve.” Read full story Source: The Guardian, 20 October 2023
  7. News Article
    A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023
  8. News Article
    Derby and Burton’s maternity services are now among the “most challenged in England”, requiring national involvement to boost improvements. The University Hospitals of Derby and Burton NHS Foundation Trust joins 31 other NHS trusts across England which are now under closer scrutiny aimed at improving the quality of maternity services. A report from the trust details that it asked to be added to the national NHS England Maternity Safety Support Programme (MSSP) "voluntarily". Midwifery and obstetric improvement advisors have now been allocated to the trust to spend two days a week on the trust’s sites and also to provide “virtual” assistance. A letter to Stephen Posey, the trust’s chief executive, sent by Sascha Wells-Munro, the deputy chief midwifery officer for NHS England, details that the organisation’s addition to the national support programme comes after a number of concerning reports – not just its request. It references the Healthcare Safety Investigation Branch report, published in February, which highlighted the cases of seven women and their babies between January 2021 and May 2022, with three mothers and a baby dying and four mothers suffering extreme consequences. Read full story Source: Derbyshire Live, 13 September 2023
  9. News Article
    Leaders of two maternity services have been told to take urgent action, after inspectors found understaffing and declining levels of care, despite safety warnings from midwives. Maternity services at University Hospital North Durham and Darlington Memorial Hospital have been downgraded from “good” to “inadequate” in Care Quality Commission reports, published today. The CQC noted a “concerning deterioration” in the care the two services provided, despite midwives telling managers they felt the service was unsafe. Sue Jacques, chief executive of County Durham and Darlington Foundation Trust, which runs the hospitals, said the CQC’s findings would be taken “extremely seriously”. The reports also said staff reported “feeling ‘frozen out’ or that their concerns were ignored by leaders” and that staff felt “‘continuity of carer’ was the trust’s main focus, despite depleted safe staffing levels, skill mix, and staff being pulled in to cover acute areas on a frequent basis”. Last year, trusts were told not to pursue continuity of carer models – which were previously championed by NHS England – unless they had adequate staffing levels to do so safely. Read full story (paywalled) Source: HSJ, 15 September 2023
  10. News Article
    Women are being "failed at every stage" when it comes to maternity care, say campaigners, as they call for more support for those experiencing traumatic births. Mumsnet found 79% of the 1,000 women who answered their questionnaire had experienced some form of birth trauma, with 53% saying it had put them off from having more children. And according to the snapshot of UK mothers, 44% also said healthcare professionals had used language implying they were "a failure or to blame" for what happened. Conservative MP Theo Clarke is leading calls for more action after her own experience, where she thought she was "going to die" after suffering a third degree tear and needing emergency surgery. Now, she has set up an all party parliamentary group on birth trauma. She said: "[It is] clear that more compassion, education and better after-care for mothers who suffer birth trauma are desperately needed if we are to see an improvement in mums' physical wellbeing and mental health. "It is vitally important women receive the help and support they deserve." Chief executive of Mumsnet, Justine Roberts, said the trauma had "long-lasting effects", adding: "It's clear that women are being failed at every stage of the maternity care process - with too little information provided beforehand, a lack of compassion from staff during birth, and substandard postnatal care for mothers' physical and mental health." Read full story Source: Sky News, 15 September 2023
  11. Content Article
    This is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
  12. Content Article
    The Care Quality Commission (CQC) State of Care is an annual assessment of health care and social care in England. The report looks at the trends, shares examples of good and outstanding care, and highlights where care needs to improve.
  13. Content Article
    This is the tenth MBRRACE-UK annual report and details the care of 572 women who died during pregnancy, or up to one year after pregnancy between 2019 and 2021 in the UK. The report also includes confidential enquiries into the care of women who died between 2019-2021 in the UK and Ireland from haemorrhage, amniotic fluid embolism, anaesthetic causes, sepsis, general medical and surgical disorders, epilepsy and stroke. By global standards, giving birth in the UK is safe, but the data reported this year should be taken as a warning signal concerning the state of maternity services and the consequences of increasing inequalities and social complexities. While Covid-19 is a significant feature of the deaths reported this year, the pandemic must not distract from wider trends. The Government’s ambition in England was to reduce maternal mortality by 50% between 2010-2025. This target is unlikely to be met. Since 2009-11, maternal mortality has increased by 15%. Crucially, the figures detailed in this report are from before the cost-of-living crisis of 2022-23. When the deaths due to Covid-19 are excluded, maternal death rates are very similar to those in 2016. There is concern that we risk losing the gains made in previous decades. Downloads Lay summary Full report Infographics Themed Surveillance Report Themed Maternal Morbidity Report Themed Maternal Mortality Report
  14. Event
    until
    The Maternity Consortium is hosting a free virtual event sharing examples of good practice from Local Maternity and Neonatal Systems (LMNS) working in partnership with Voluntary Community and Social Enterprise (VCSE) organisations and Maternity and Neonatal Voices Partnerships (MNVPs) to implement their equity and equality plans. The event will also include a national update on the equity and equality plans from NHS England and an opportunity to network with colleagues in breakout rooms. Who should attend? The event is open to anyone working in the maternity and neonatal space, including in LMNSs, Trusts, regions, specialist perinatal/maternal mental health services, the VCSE sector, local authorities, MNVPs, service user voice representative roles, other frontline services, and academia. Agenda Introduction from the Maternity Consortium Presentation from NHS England Presentation from North East and North Cumbria LMNS Presentation from Suffolk and North East Essex LMNS Breakout rooms About the Maternity Consortium Tommy’s and Sands are co-leading the Maternity Consortium as members of the VCSE Health and Wellbeing Alliance. The Maternity Consortium includes: National Maternity Voices, Pregnancy and Baby Charities Network, Five X More, Muslim Women’s Network UK and LGBT Mummies. The Maternity Consortium's aim is to use our collective expertise to join up national and local voices behind a common agenda: to reduce health inequalities for families throughout the whole pregnancy journey from pre-conception and through the first year of a baby’s life. Contact: Celeste Pergolizzi, Maternity Consortium Coordinator and Engagement Lead, celeste.pergolizzi@sands.org.uk Sign up for the event
  15. Content Article
    This study aims to explore minority ethnic women’s experiences of perinatal mental health services during COVID-19 in London. Methods: Eighteen women from ethnic minority backgrounds were interviewed, and data were subject to a thematic analysis. Results: Three main themes were identified, each with two sub-themes: ‘Difficulties and Disruptions to Access’ (Access to Appointments; Pandemic Restrictions and Disruption), ‘Experiences of Remote Delivery’ (Preference for Face-to-Face Contact; Advantages of Remote Support); ‘Psychosocial Experiences’ linked to COVID-19 (Heightened Anxiety; Social Isolation). Conclusions: Women from ethnic minority backgrounds experienced disrupted perinatal mental health care and COVID-19 restrictions compounding their mental health difficulties. Services should take women’s circumstances into account and provide flexibility regarding remote delivery of care.
  16. News Article
    Women have faced delays in giving birth due to the ongoing strikes, a major trust’s chief executive has said. Matthew Hopkins, who joined Mid and South Essex Foundation Trust last month, told a board meeting on Thursday that industrial action was having a “significant and growing” impact on patients. He added that this extended beyond delays to outpatient appointments and elective operations, saying: “It is also delaying mums giving birth, because we are seeing delays now in being able to conduct our elective Caesarian sections.” Mr Hopkins said the impact was also “really significant” on staff, with those covering for colleagues “very, very tired”. “It is important we give a very clear message to the two sides of the argument – government and the [British Medical Association] – that we need a light at the end of the tunnel, and staff need a light at the end of the tunnel. “Going into winter, with this continuing disruption for our patients and our staff, is in my view unacceptable.” Read full story (paywalled) Source: HSJ, 28 September 2023
  17. News Article
    A consultant obstetrician has claimed he was sacked from his hospital for raising whistleblowing concerns about patient safety over fears they would cause “reputational damage”. Martyn Pitman told an employment tribunal in Southampton that managers dismissed his concerns and he was “subjected to brutal retaliatory victimisation” after he criticised senior midwife colleagues. He said: “On a daily basis there was evidence of deteriorating standards of care. We were certain that the situation posed a direct threat to both patients’ safety and staff wellbeing. Concern was expressed that there was a genuine risk that we could start to see avoidable patient disasters.” Rather than addressing these, Pitman said the trust had considered it “the path of least resistance to take out [the] whistleblower”. Pitman was dismissed this year from his job at the Royal Hampshire County hospital (RHCH) in Winchester, where he had worked as a consultant for 20 years. He is claiming he suffered a detriment due to exercising rights under the Public Interest Disclosure Act. He said he “fought against [an] absolute barrage of completely unprofessional assaults on me” after he raised concerns about foetal monitoring problems that resulted in the death of a baby and the delivery of another with severe cerebral palsy. Read full story Source: The Guardian, 26 September 2023
  18. Content Article
    The well-being of Black mothers during and after pregnancy has been disproportionately affected by cultural barriers that hinder access to adequate mental health care. Addressing and breaking these barriers is essential to ensuring the well-being of Black mothers and promoting healthy outcomes for their children. Black Maternal Mental Health Week is led by The Motherhood Group and the theme for 2023 is Breaking Cultural Barriers.
  19. News Article
    Hospitals are still promoting a “natural birth is best” philosophy – despite a succession of maternity scandals highlighting the dangers of the approach. A Telegraph investigation has found a number of trusts continuing to push women towards “normal” births – meaning that caesarean sections and other interventions are discouraged. On Saturday, the Health Secretary has expressed concern about the revelation, vowing to raise the matter with senior officials. Guidelines for the NHS make it categorically clear that a woman seeking a caesarean section should be supported in her choice, after “an informed discussion about the options”. Maternity services were last year warned by health chiefs to take care in the language they used, amid concern about “bias” towards natural births. The warning from maternity officials followed concern that women were being left in pain and fear, with their preferences routinely ignored. The findings come 18 months after Dame Donna Ockenden published a scathing report into maternity care at Shrewsbury and Telford NHS Trust, which warned that a focus on natural birth put women in danger. Read full story (paywalled) Source: The Telegraph, 23 September 2023
  20. Content Article
    Harry's Story is a website set up by Derek Richford, the grandfather of Harry Richford, who died in November 2017 at just a week old following failures in care during and after his birth. The site outlines how Harry's family worked tirelessly to uncover what happened to Harry and the poor standard of care at the maternity unit at East Kent University Hospitals Foundation Trust (EKUHFT). It covers the following aspects of the family's experience: Our Investigation The Inquest Cover Up? - You Decide HSIB Involvement What Happened Next The Kirkup Inquiry Accountability Harry's Legacy The site also contains a section offering advice for parents whose babies die or suffer harm in hospital during the perinatal period.
  21. Content Article
    I am passionate about women's health and have worked with campaigners, clinicians and patients for a number of years to look at the barriers that women face in receiving safe care and the challenges clinicians face in delivering it.   We know the medical system has historically been based on the white, male patient which has led to huge gaps in knowledge and understanding around women's health. But we are not just playing catch up to address past racism and patriarchy that is embedded in the system, we are continuing to highlight and fight it where it still exists.   On Saturday I attended the Women's Health Summit, organised by Five X More. It was a powerful event, designed to look at aspects of women's health throughout their life journey. Attended by mums, charity representatives, media, clinicians, patients, leaders and more, united by a desire to change things.   I laughed, I talked and I cried.   One of the final calls to action of the day was to find your skill, find your voice and do more.   So, I start where I am most at home - in writing. 
  22. Content Article
    The Maternal, Newborn and Infant Clinical Outcome Review Programme, which is delivered by MBRRACE-UK, has published a report on UK Perinatal Deaths for Births from January to December 2021. Overall, it found that perinatal mortality rates increased across the UK in 2021, with 3.54 stillbirths per 1,000 total births and 1.65 neonatal deaths per 1,000 live births (3.33 and 1.53 respectively in 2020). However, there was a wide variation in stillbirth and neonatal mortality rates across organisations, though these rates increased in almost all gestational age groups. It was also found that inequalities in mortality rates by deprivation and ethnicity remain, but the most common causes of stillbirth and neonatal death are unchanged (for example, congenital anomalies continue to contribute to a significant proportion of perinatal deaths).
  23. Content Article
    In 2008, five ‘serious untoward incidents’ occurred on a small maternity unit in a hospital in the UK. The prevailing view, held by clinical staff, hospital managers, and executives, was that these events were unconnected and did not signal systemic failures in care. This view was maintained by the testimony of staff and governance procedures which prevented the incidents from being considered together. Drawing on the inquiry report of the Morecambe Bay Investigation (2015), Dawn Goodwin examines how the prevailing view was built and dismantled, eventually being replaced with a very different description of events. Overturning this view required affected parents to engage with governing bodies and legal processes, challenge clinical staff, lobby for inquests, and mobilise social media and the national press. Tracing how different descriptions of events weaken or gather force as they travel through different forums, processes, and are presented to different audiences, she explores the sociology of knowledge around establishing failures of care.
  24. News Article
    A trust facing a police investigation into one of the NHS’s largest ever maternity scandals is no longer rated ‘inadequate’ by the Care Quality Commission in its well-led and maternity domains. Nottingham University Hospitals Trust was rated “inadequate” for its leadership and maternity services during inspections in 2021 and 2022, following serious care failings exposed by staff and patients during this period. The Nottinghamshire police confirmed last week they were opening an investigation. But the regulator noted improvements after its well-led and maternity inspections which took place in April and June. The well-led rating has gone up from “inadequate” to “requires improvement” and maternity services at both hospitals have also gone up to “requirements improvement”. Greg Rielly, CQC deputy director of operations in the Midlands, said: “During this inspection, we saw a team that consistently led with integrity who were open and honest in their approach.” However, he stressed that while the culture across the trust was improving, some staff still didn’t feel able to raise concerns without fear of retribution. “Leaders were aware of this and were working to create a workplace that is free from bullying, harassment, racism, and discrimination so we hope to see an improved picture soon,” he said. Read full story (paywalled) Source: HSJ, 13 September 2023
  25. News Article
    A police investigation is to be launched into failings that led to dozens of baby deaths and injuries at a hospital trust. The maternity units at Nottingham University Hospitals (NUH) NHS Trust are already being examined in a review by senior midwife Donna Ockenden. The review will become the largest ever carried out in the UK, with about 1,800 families affected. Nottinghamshire Police said its decision to investigate followed discussions with Ms Ockenden. Her team is looking into failings that led to babies dying or being injured at Nottingham City Hospital and the Queen's Medical Centre. Chief Constable Kate Meynell said: "On Wednesday I met with Donna Ockenden to discuss her independent review into maternity cases of potentially significant concern at Nottingham University Hospitals NHS Trust (NUH) and to build up a clearer picture of the work that is taking place. "We want to work alongside the review but also ensure that we do not hinder its progress. "However, I am in a position to say we are preparing to launch a police investigation. "I have appointed the Assistant Chief Constable, Rob Griffin, to oversee the preparations and the subsequent investigation." Read full story Source: BBC News, 7 September 2023
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