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Found 500 results
  1. Content Article
    .As healthcare organisations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. This handbook was published by Healthcare Improvement Scotland to support NHS board maternity services to: understand the importance of safety culture. undertake a patient safety climate survey. understand what the survey results are telling them. develop an improvement plan to address areas that have been highlighted. It includes: the Maternity Services Patient Safety Survey. template letters for NHS boards to adapt for local use. an example improvement plan template.
  2. Content Article
    Georgia Stevenson discusses NHS England’s Long Term Workforce Plan, evaluating its potential to alleviate staffing shortages, enhance training routes, and ultimately improve care quality in maternity and neonatal services.
  3. Content Article
    This briefing was commissioned by the Maternal Mental Health Alliance who are dedicated to ensuring all women, babies and their families across the UK have access to compassionate care and high-quality support for their mental health during pregnancy and after birth. One woman in five experiences a mental health problem during pregnancy or after they have given birth. Maternal mental health problems can have a devastating impact on the women affected and their families. NICE guidance states that perinatal mental health problems always require a speedy and effective response, including rapid access to psychological therapies when they are needed. Integrated care systems (ICSs) have a unique opportunity to ensure that all women who need support for their mental health during the perinatal period get the right level of help at the right time, close to home. Key points Maternal mental health problems are common and can be extremely serious. Timely access to effective help can make a big difference to long-term health outcomes for mothers and generations to come Integrated care systems can ensure that comprehensive and evidence-based support is provided to women and birthing people during the perinatal period Maternal mental health care must be developed equitably, adapting to the needs of groups of women with higher risk and poorer access to effective support Universal services – midwifery, general practice, and health visiting – are vital to identify needs and provide timely support Access to NHS Talking Therapies is essential for women with many diagnosable mental health difficulties during the perinatal period Specialist community perinatal mental health services are a priority for the NHS Long Term Plan and can meet the needs of women with more serious and complex conditions Adequate provision of specialist Mother and Baby Inpatient Units prevents women being separated from their babies if they need to be admitted to hospital The voluntary sector, including peer support, plays a vital role and needs to be commissioned and properly funded
  4. Content Article
    The Maternity Survey 2022, run by Ipsos on behalf of the Care Quality Commission, looked at the experiences of women and other pregnant people who had a live birth in early 2022. In this article Anita Jefferson from Ipsos looks at the results of this and considers what they tell us about experiences of maternity services. Results from the Maternity Survey 2022 that this article highlights includes: Across the maternity pathway there has been a decline in the proportion of respondents who say they can always get help when they need it. Related to the availability of staff, the provision of information and advice has also dropped. While most (82%) respondents felt they were given appropriate advice and support at the start of their labour, this is a drop from 88% in 2019 and 84% in 2021. Almost a quarter of women and people who had given birth (23%) felt that when they raised a concern during labour and birth, it was not taken seriously. There are some areas of care that have seen an upward trend across the years. One of these is the experience of discharge from hospital, where around two-thirds of women and other people who had given birth report no delay to their discharge (62%, up from 56% in 2019). The results show an improved experience around support for mental health across the maternity pathway.
  5. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations. The report lists the following highlights from HSIB’s maternity investigation programme during 2022/23: During 2022/23, the maternity investigation programme completed 702 reports. This was a similar figure to previous years. At any one time there were approximately 355 active investigations. The number of investigation referrals relating to brain injury indicate a sustained decrease in babies with abnormal MRI results or neurological damage. In the last year, the programme made more than 1,380 safety recommendations to trusts and other healthcare organisations, covering various topics. Families remain central to the work HSIB undertake. HSIB contact all families who give their consent; of these 86% agreed to participate and 14% declined further participation in the investigation. As part of HSIB’s initial engagement and ongoing communication with families they have been supported with interpretation/translation services on 670 occasions. Information provided to families about HSIB investigations has been translated into 36 languages. This helps families to make informed choices about participating in investigations and provides better support to enable their ongoing involvement. HSIB’s reports, and those of other organisations such as MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK), have identified racial differences in maternity outcomes. HSIB has formed a race equality group to develop the data from investigations to analyse demographics and understand the impact of racial diversity on experiences, access to care, and outcomes. The quarterly review meetings HSIB undertake with trusts have continued to develop with greater engagement from executive-level staff, board-level maternity safety champions, and the frontline perinatal teams. By working closely with trusts, the programme has helped to increase the involvement of perinatal teams in patient safety. The programme has deepened the understanding of the role of emerging themes and how they help to identify issues in the healthcare system as a whole that contribute to the harm experienced by pregnant women/people and their families. HSIB now publish a national newsletter three to four times a year to support trusts in sharing improvements they have made in response to safety recommendations, providing learning opportunities across England and beyond. A Maternity Quality Matrix is being rolled out to trusts to provide insight into their HSIB maternity investigations over time. Feedback is received from trusts and the HSIB Maternity Quality Improvement Team continues to improve investigations and support processes. During investigations, ‘soft intelligence’ relating to the investigation is captured in a maternity observational diary, which shares concerns as well as good practices with trusts, and information about ongoing challenges. Members of the maternity team ongoingly present at regional and national meetings to share their work and findings from reports.
  6. Content Article
    The aim of the study was to explore the factors that affect the safety attitude and teamwork climate of Cyprus maternity units and Cypriot midwives. The study found that the safety climate in the maternity settings was negative across all six safety climate domains examined. The higher mean total score on team work and safety climate in the more experienced group of midwives is a predominant finding for the maternity units of Cyprus. It could be suggested that younger midwives need more support and teamwork practice, in a friendly environment, to enhance the safety and teamwork climate through experience and self-confidence.
  7. Content Article
    This report by the Royal College of Midwives (RCM) highlights the impact of midwifery staffing shortages on women. It looks at historical failures to invest appropriately in maternity services and talks about a mounting maternity crisis, drawing attention to Care Quality Commission inspections of maternity services that are identifying concerns around safety directly linked to staffing shortages. According to the report’s findings, if the number of NHS midwives in England had risen at the same pace as the overall health service workforce since the last general election, there would be no midwife shortage; there would be 3,100 more midwives in the NHS, rather than having a shortfall of 2,500 full-time midwives. The RCM published the results of a survey last month which showed that midwives give 100,000 hours of free labour to the NHS per week to ensure safe care for women. It also showed that staffing levels were repeatedly cited as cause for concern around the safety of care, and that midwives and maternity support workers are exhausted and burnt out.
  8. Content Article
    A vision for improving the care and support available to families when baby loss occurs before 24 weeks' gestation. This independent review sets out the government's vision for improving the care of people who experience pre-24-week baby loss. It describes a system in which: Everyone receives high-quality education about pre-24-week baby loss before they become pregnant through the statutory relationships, health and sex education (RHSE) curriculum. All groups of people – regardless of race, colour, age, gender, sexual orientation or religion – have their voices heard and choices upheld. There is clarity about whom to call and where to go when pain and bleeding occur at any stage of pregnancy, and what to expect during and after baby loss. Access to compassionate clinical care in appropriate healthcare settings is available 24 hours a day, 7 days a week through networked services. All parents receive clear and consistent information and support, enabling them to make decisions about their physical and mental health care needs during and after baby loss. Care is compassionate, individualised and respectful of personal, cultural, religious and language preferences, and parents and their babies (including baby loss remains at any gestation) are cared for with dignity and respect. Regardless of gestation, all bereaved parents are offered choices regarding creating memories of their baby and options regarding marking their loss, such as funerals or memorial ceremonies, as appropriate. Women and partners experiencing loss are routinely offered mental health support following a loss, and have access to specialist counselling and mental health services, where appropriate. Bereaved parents can, on request, receive a baby loss certificate from the government, whether their loss was recent or historic. Following a baby loss, individuals and couples are supported to understand why the loss occurred, and are offered a follow-up appointment to discuss the results and implications of any investigations. A robust management plan must be in place for subsequent pregnancies – this may include referral to a specialist consultant obstetrician or gynaecologist. All healthcare professionals working in baby loss services receive multidisciplinary mandatory bereavement care training and information, including education on the importance of psychological wellbeing and self-care for staff to ensure they can provide the highest quality of care. Staff should be allocated time to attend, and their compliance should be monitored. Employers recognise the impact of baby loss on employees and human resources (HR) policies are updated to support their staff There are systems in place for employers to manage the potential impacts on the mental health and wellbeing of all staff employed in workplaces providing baby loss services.
  9. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. The investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. In its formal report, published on the 19 October 2022, it stated that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. At the beginning of its response to the Investigation and its recommendations, the Government states that at a national level, the Minister for Mental Health and Women’s Health Strategy will chair a newly created maternity and neonatal care national oversight group. This will bring together the key people from the NHS and other organisations, including the CQC and HSIB, to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews, to ensure a joined-up and effective approach. Summary of the Government response to each of the recommendations Recommendation – The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use. NHS England (NHSE) has established a Reading the Signals Data Co-ordination Group, referred to in this report as the co-ordination group, who will bring together a series of data projects which aim to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes. NHSE have also formed a Maternity and Neonatal Outcomes Group, acting as a task force in response to the recommendation in the East Kent report. Chaired by Dr Edile Murdoch, this group has met and is progressing work towards the identification of outcome measures that will, as this recommendation states, differentiate signals among noise to display significant trends and outliers. Recommendation – Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning. Department of Health and Social Care (DHSC) will lead the response to this recommendation in a central coordination role involving relevant national partners, closely supported by NHSE. It will coordinate activity to: Map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training. Share good practice and examples of how barriers have been overcome with all those responsible for training, from higher education institutions to those providing preceptorship and clinical supervision at trust level, on the embedding of compassionate care. Identify where gaps depend on national level change or coordination and work with relevant bodies or other government departments to consider how these could be addressed. This will also consider how the government, NHSE and other arm’s length bodies can influence and support sustainable system level change. Recommendation – Relevant bodies, including Royal Colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance. DHSC will lead the response to this recommendation, in a central coordination role looking across the whole system. This work will be supported closely by NHSE. It will coordinate activity to: Map current responsibilities around oversight and direction. Share good practice and learning on proposed solutions to address gaps in roles and responsibilities in oversight and direction, and support for managing concerns about practice. Identify where gaps in oversight depend on national level change or coordination and work with relevant bodies or other government departments to consider addressing these. This will include examination of where regulators could contribute to identification of poorly performing trusts. Recommendation – Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset. DHSC will lead the response to this recommendation in a central coordination role, with the close support of NHSE. It will coordinating reports that will: Provide evidence through experience and examine existing research on how and where teamwork is being done well. Bring together examples of good practice to support trusts and all those supporting teamwork to utilise as a resource of solutions to barriers and identified gaps. Consider whether, where gaps and barriers are identified, relevant bodies or government can support solutions. Recommendation – Relevant bodies, including Health Education England, Royal Colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development. DHSC will lead the response to this recommendation and be supported closely by NHSE. It will coordinate reports that will: Map how the support for junior doctors, and those who have yet to complete training including locums, is translated into practice, what access they have to development and how teamwork is embedded within this. Identify and share good practice and learning around proposed solutions to address gaps in roles and responsibilities for supervision for specific groups. Consider whether the government and its arm’s length bodies (ALBs) need to provide support to the system to address gaps and barriers. Recommendation –The Government reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies. Recommendation – Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards. Recommendation – NHSE reconsider its approach to poorly performing trusts, with particular reference to leadership. The Government has provided one response to the above three recommendations which includes the following points: The government acknowledges the failure to adhere to this duty of candour that was so evident in this report and recognises the need for action in this area in order to make sure the duty is effectively applied and to create a culture of candour throughout organisations. When considering the broader recommendation made by Dr Kirkup for a bill to place a “duty on public bodies not to deny, deflect and conceal information from families and other bodies”, the government will set out its position in response to Bishop James Jones’ 2017 report on the experiences of the families bereaved by the Hillsborough disaster in due course. To help monitor when reputation management is superseding transparency of trust boards, the CQC, as part of its new inspections approach, will continue to consider trust leadership at executive team and trust board level as part of its key lines of enquiry, using the well led framework. In the 2023 to 2024 financial year, NHSE is commissioning a support programme for board safety champions to focus on developing the leadership, culture and processes needed for them and their teams to be able to use qualitative and quantitative data to improve maternity and neonatal safety in their organisations. Recommendation – The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input. In their response the Government note the actions that the Trust has taken following the publication of the report on the 19 October 2022, including that specific improvements in maternity and neonatology services will be overseen by a maternity and neonatal assurance group, reporting to the Trust’s board. Related reading 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022) Prevention of Future Deaths Report: Harry Richford (3 February 2020) Patient Safety Learning: Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report (17 November 2022)
  10. Content Article
    NHS Resolution has launched its first eLearning module that focuses on learning from the significant avoidable harm that can occur during antenatal and postnatal care and is seen in the cases notified to its Early Notification Scheme. This free resource is designed to support clinicians working in maternity services. The module uses three illustrative case stories to immerse learners into the antenatal, intrapartum and postnatal care provided to mothers and the neonatal care provided to their babies. It aims to deepen learners' understanding of NHS Resolution’s role within the healthcare system, develop their understanding of the law of negligence as applied to clinical claims and explore how clinical decisions and actions can lead to avoidable harm. The module takes approximately two-and-a-half hours to complete and can be used as evidence of CPD hours undertaken for revalidation.
  11. Content Article
    Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. The objective of this study was to quantify trends in MMRs (maternal deaths per 100 000 live births) by state for five mutually exclusive racial and ethnic groups using a bayesian extension of the generalised linear model network. The study found that while maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.
  12. Content Article
    Since retiring from his role in public health, Dr Bill Kirkup has focused on independent investigations into public service failures, including maternity services at Morecambe Bay and East Kent. In this podcast, Bill talks to Parliamentary and Health Service Ombudsman Rob Behrens about his career, what he's learnt during his investigations and how we can make more progress in improving patient safety.
  13. Content Article
    On the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report. Below is a brief summary of some of the key elements of the Government’s response to the report’s recommendations. Their response can be read in full here. The Government rejected a recommendation to commit to increasing the annual budget for maternity services to £200–350 million from the next financial year. The Government rejected a recommendation that there should be a cross-government target and strategy, led by the Department of Health and Social Care, for eliminating maternal health disparities. The Government accepted partially accepted a recommendation to update the Committee on a six-monthly basis on the progress of the Maternity Disparities Taskforce. However, it declined to publish minutes of Taskforce meetings or publish measures for gauging the success of the Taskforce as requested in the report. The Government partially accepted a recommendation to conduct a co-ordinated review to ensure that both the training curricula and continuing professional development requirements for all maternity staff include evidence-based learning on maternal health disparities, its possible causes, and how to deliver culturally competent, personalised and evidence-led care. It stated that NHS England would carry out a scoping exercise to fully understand the implications of co-ordinating this review and determine how best to bring the relevant stakeholders together. In response to a recommendation that NHS England should set out their approach for assessing and monitoring the strategies of local maternity services, the Government said each Local Maternity and Neonatal System has produced an Equity and Equality Action Plan which will be published by 31 March 2024. The Government did not advise on timescales for the roll-out of the maternal morbidity indicator as requested by one of the report’s recommendations.
  14. Content Article
    Postpartum hypertensive disorders pose a serious health risk to new mothers; nearly 75 percent of maternal deaths associated with hypertensive disorders occur in the postpartum period. For the past decade, the obstetrics department at the Hospital of the University of Pennsylvania (HUP) has tried to lower these risks by checking patients’ blood pressure after they are released from the hospital. Their initial efforts to have patients return to the office for an in-person blood pressure check shortly after discharge yielded disappointing results, so the team revamped their approach and ultimately developed an extremely successful program called Heart Safe Motherhood. The programme started when the team at HUP gave a small group of women a blood pressure cuff each. They told them they would receive text messages after discharge instructing them to take their blood pressure at 8am, and that they would need to send in the reading. At 1pm, they would get another text requesting that they send their blood pressure again. This article describes how Heart Safe Motherhood evolved to improve the likelihood of mothers submitting their readings, and how the programme was scaled up to five hospitals in the group. It looks at how the approach has helped tackled health inequalities and improved the safety of postpartum mothers.
  15. Content Article
    This study in BMJ Open Quality aimed to assess the patient safety status in selected hospitals in Ghana. The authors concluded that the current patient safety status in the hospitals in the study was generally good, with the highest score in the knowledge and learning in the patient safety domain. Patient safety surveillance was identified as the weakest action area.
  16. Content Article
    In 2022, an illustration of a Black foetus in the womb by Nigerian medical illustrator and medical student Chidiebere Ibe, went viral. The image sparked an important conversation around representation in medical imagery and the impact this has on health outcomes for patients who are Black, Indigenous and people of colour (BIPOC). Research showed that only 5% of medical images show dark skin and only 8% of medical illustrators identified as BIPOC. A collaboration between Chidiebere Ibe, Deloitte and Johnson & Johnson, Illustrate Change aims to build the world's largest library of BIPOC medical illustrations for use in medical education and training. So far, the library contains images relevant to the following specialties: Dermatology Eye disease General health Haematology Maternal health Oncology Orthopaedics
  17. Content Article
    Race and ethnicity have been associated with poor pregnancy outcomes in many countries. In the UK, the rates of baby death and stillbirth among Black and Asian mothers are double those for White women. Most studies examine trends for individual countries. This large database study explored how race and ethnicity is linked to pregnancy outcomes in wealthy countries. Key findings Black women consistently had worse outcomes than White women across the globe.  Hispanic women were three times more likely to experience baby death compared with White women.  South Asian women had an increased risk of early birth and having a baby with an unexpectedly low weight (small for the length of pregnancy) compared with White women.  Racial disparities in some outcomes were found in all regions. The researchers call for a global, joined-up approach to tackling disparities. Breaking down barriers to care for ethnic minorities, particularly Black women, could help. More research is needed to understand why outcomes are for worse for ethnic minorities. The researchers recommend routine collection of data on race and ethnicity. The link below takes you to the Plain English summary of the research, you can also view the full research study.
  18. Content Article
    Potential serious risks to patient safety have been identified with the use of Magentus Software Limited’s Euroking maternity information system. These concern specific data fields: certain new patient information, recorded during a patient contact, can overwrite ('back copy') information previously recorded in the patient’s pregnancy record. certain pregnancy-level data (information relevant only to a specific pregnancy event) can be saved at a patient level (where information relevant throughout a person's life is recorded), causing new information to overwrite (‘back copy’) previously recorded data across an entire patient record. certain recorded pregnancy-level data can pre-populate into new pregnancy records (‘forward copy’), which can mean clinicians will see incorrect patient information, and attempts to correct this can result in the issue described at (ii) above. Actions Organisations using Euroking: 1. must consider if Euroking meets their maternity service’s needs and ensure that their local configuration is safe. To do this they will need to work with their supplier to make changes to their existing system, and this will need to be overseen by their clinical safety officer. 2. must review and ensure that each data field within the system does not copy forward or backward. 3. if procurement of a new system is deemed necessary, organisations must ensure that all clinical information is appropriately backed-up, accessible for any future requirement and, when Euroking becomes a legacy system, must comply with action Organisations with legacy Euroking contracts: 4. must implement a process to ensure users who access any legacy Euroking records will be alerted to the issues identified in this alert. Organisations currently using another maternity information system/EPR: 5. must reassess the clinical safety of their maternity EPR with a suitably qualified clinical safety officer and, as a minimum, must ensure that the issues listed under ‘Additional information’ relating to the back and forward copying of information do not occur. 6. must assess that their current maternity EPR complies with the core maternity capabilities in the Maternity Digital Capabilities Framework.
  19. Content Article
    Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear. The aim of this study from Mary Dixon-Woods and colleagues was to identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010–2023, and to conduct a structured quality assessment. They found poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.
  20. Content Article
    The latest Care Quality Commission (CQC) report on the state of care in England is far from an encouraging read.1 Although the healthcare system is under serious strain, maternity services are among the areas identified as especially challenged. The problems identified in maternity care, while shocking, come as no surprise. The sector is seeing repeated high profile organisational failures and soaring clinical negligence claims, together with grim evidence of ongoing variation in outcomes, culture, and workforce challenges and inequities linked to socioeconomic status and ethnicity. In this BMJ Editorial, Mary Dixon-Woods and colleagues discuss why it's time for a fresh approach to regulation and improvement.
  21. Content Article
    *Trigger warning: This report contains accounts of bullying behaviours and consequences and may trigger those who have experiences of bullying. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. In the numerous accounts shared all areas of the system from CQC, CEO, HR, midwifery management, universities and the unions are described as being complicit, inadequate, disinterested and even corrupt. Accounts also refer to: Unsafe work environments Exit interviews not being performed, recorded or acted upon Staff not being valued Whistle-blowers being demonised until they leave Health and safety issues and truly evidence-based practice ignored with no lessons learned. To order your copy, follow the link below.
  22. Content Article
    Trust boards’ regular oversight of the quality and safety of maternity and neonatal services has been the subject of successive inquiries and reviews. In this report, the Sands and Tommy’s Joint Policy Unit review publicly available board papers and minutes for seven NHS Trusts in England. They analyse whether the information presented to boards, the process for review, and actions taken enabled boards to deliver effective oversight over the safety and quality of maternity and neonatal services. The review highlights the following policy and practical needs: The need for clearer guidance on the minimum metrics required by boards, which should include any new measures identified by the Maternity and Neonatal Outcomes Group to provide an early warning of service quality and safety declining. Better ward-to-board communication is required to contextualise data and findings. They state that this requires integrating more insights from Clinical Service Leaders in reports to the board to contextualise the metrics presented, as well as board members’ engagement with wards and staff. Reports to the board should include reviews over a longer time frame. Review current systems and processes in each Trust and whether they allow boards to have meaningful oversight over the quality and safety of services. They make the case that there is a need to review the meeting frequency and/or length to ensure sufficient time for meaningful scrutiny or to delegate this scrutiny further, alongside improved transparency of committee-level discussions. Transparent reporting of the issues discussed outside of public board meetings, such as at sub-committee level. The need to review the extent to which the maternity incentive scheme in its current form incentivises transparent reporting of performance issues so that they can be addressed in a timely way. It states that there is a risk that the boards and services focus on demonstrating compliance with the scheme rather than supporting the improvements in safety. Clarity over the role of Local Maternity and Neonatal Systems in oversight of quality and safety and the implications for Trust boards’ responsibilities.
  23. 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. This collaboration began from a shared desire to spotlight the needs of young mums and their mental health and how to improve perinatal mental health provision in an inclusive way. The reality is: postnatal depression is up to twice as prevalent in teenage mothers compared to those over 20 1 in 4 births in England and Wales were to young people aged 16-24 there has been a tragic rise in teenage maternal suicides. This report shines a light on the urgent needs of young mums and how across the UK, we must make the report’s recommendations a positive reality. Based on the experiences and insights received from young mothers and the evidence collated in the literature review, the briefing identifies four priority areas for action to better support the needs of young mothers: Listen and respond to the needs of young mothers in national and local systems Resource and invest in universal and preventative services Ensure access to specialist mental health services Research and listen to the voices of young mums.
  24. 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.
  25. 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.
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