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Found 404 results
  1. News Article
    Maternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said. A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year. An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018. Read full story Source: The Independent, 6 December 2019
  2. News Article
    NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
  3. Content Article
    Too often, women are struggling to get the right information they need about their health, to book routine appointments and to get their basic health needs met. Health services miss opportunities to ask the right questions, prevent illness and ensure the best outcomes for girls and women. This report from the Royal College of Obstetricians and Gynaecologists (RCOG) follows a survey of over 3000 women in the UK and identifies simple and cost-effective solutions to prevent girls and women falling through the cracks of our health systems. A strategic approach is required across the life course to prevent predictable morbidity and mortality and to address the determinants of health specific to women’s health. 
  4. News Article
    UK women face widespread barriers to essential healthcare services. A survey of over 3,000 women in the UK shows many are struggling to access basic healthcare services including contraception, abortion care and menopause support . The Royal College of Obstetricians and Gynaecologists (RCOG) calls for one-stop women’s health clinics to provide healthcare needs for women in one location and at one time. The RCOG launched a landmark report “Better for Women” – to improve the health and wellbeing of girls and women across their life course – in The House of Commons. The RCOG is calling for better joined up services, as part of its 'Better for Women' report. It emphasises the need for national strategies to meet the needs of girls and women across their life course – from adolescence, to the middle years and later life. Read full report
  5. Content Article
    Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.
  6. News Article
    Large numbers of previously missed abnormalities have been uncovered in the biggest review of smear tests undertaken since cervical cancer screening began in Ireland. The review led by the Royal College of Obstetricians and Gynaecologists in the UK has found hundreds of “discordant” results after re-examining the slides of over 1,000 women who had been tested for the disease under CervicalCheck, were given the all-clear and later developed cancer, according to an informed source. Discordant means the re-examination of the smear test by Royal College reviewers has produced a result that is different from the original finding by CervicalCheck. The extent of the individual divergences from the initial results is not yet known, but the review has found some cancers could have been prevented, it is understood. The college is due to submit an aggregate report on its findings to Minister for Health Simon Harris shortly. Read full story Source: The Irish Times
  7. News Article
    More than a third of maternity doctors are “burnt out,” and at risk of lacking empathy for the women in their care, researchers have warned. The study of more than 3,000 obstetricians and gynaecologists found high levels of long-term stress and overwork, especially among trainee medics. Researchers said the findings – from the largest UK study on the topic – were “very worrying,” with serious implications for patients. Overall, 36% of those surveyed met the criteria for “burnout,” which is associated with emotional exhaustion, lack of empathy and connection with others, researchers said. Medics who met the criteria for burnout were three times as likely to report anxiety, irritability and anger. They were also four times more likely than colleagues to practice “defensively”- meaning they tried to avoid difficult cases, or else carried out more interventions than necessary, for fear of error. Read full story Source: The Telegraph, 26 November 2019
  8. Content Article
    In this study published in BMJ Open, Bourne et al. determined the prevalence of burnout in doctors practising obstetrics and gynaecology, and assess the association with defensive medical practice and self-reported well-being. They carried out a nationwide online cross-sectional survey study of 5661 practising obstetrics and gynaecology consultants, specialty and associate specialist doctors and trainees registered with the Royal College of Obstetricians and Gynaecologists, between December 2017 and March 2018. They found high levels of burnout were observed in obstetricians and gynaecologists and particularly among trainees. Burnout was associated with both increased defensive medical practice and worse doctor well-being. These findings have implications for the well-being and retention of doctors as well as the quality of patient care, and may help to inform the content of future interventions aimed at preventing burnout and improving patient safety.
  9. News Article
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019
  10. News Article
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service. Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger. Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming. Read full story Source: The Guardian, 2 November 2019
  11. News Article
    In March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua. The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale. James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families." Read full story Source: The Independent, 21 November 2019
  12. News Article
    As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself. Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women." Read full story Source: The Independent, 20 November 2019
  13. News Article
    The Care Quality Commission (CQC) issued a warning notice to the West Suffolk Hospital in Bury St Edmunds, which must improve by 31 January. It has not released details but the hospital said inspectors flagged up how it recorded observations and monitored women in its care. A hospital spokeswoman said: "We have taken this feedback seriously and are acting accordingly." She added: "Concerns have been raised about how we record patient observations after we have taken them, which are currently not in line with national guidance". "The CQC also identified that we should make changes to the way we monitor women in our care, again to bring us in line with national guidance". "We are making the necessary changes and the CQC is satisfied with the plans we have in place to make the improvements required." Read full story Source: BBC News, 21 November 2019
  14. News Article
    Hundreds of women left in debilitating pain by faulty transvaginal mesh devices have won a landmark case against multinational giant Johnson & Johnson. The Australian class action against companies owned by Johnson & Johnson was won on behalf of 1,350 women who had mesh and tape products implanted to treat pelvic prolapse or stress urinary incontinence, both common complications of childbirth. The devices all but ruined the lives of many. Women have been left in severe, debilitating and chronic pain, and often unable to have intercourse. The vast majority also suffered a significant psychological toll. The mesh eroded internally in many cases, has caused infections, multiple complications, and is near impossible to completely remove, Australia’s federal court has heard. The devices were not properly tested for safety before being allowed on to the Australian market, though Johnson & Johnson and the associated companies clearly knew the potential for serious complications. The companies were accused of launching a “tidal wave” of aggressive promotion at doctors, marketing the devices as cheap, simple to insert, and a relatively risk-free way to boost profits. All the while, their potential dangers were minimised, downplayed or ignored, both in communications to doctors and patients, the plaintiffs alleged. When patients complained of pain, they were frequently disbelieved. Read full story Source: The Guardian, 21 November 2019
  15. News Article
    Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent. It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it". The trust apologised and said "a lot" had been done to address concerns. In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement. Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage. The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort". Read full story Source: BBC News, 20 November 2019
  16. News Article
    A health board criticised for severe maternity failings put too much emphasis on targets instead of patient safety, according to a new review of quality governance arrangements at Cwm Taf Morgannwg University. It found wider failings in Cwm Taf Morgannwg health board's governance. Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) also found a high level of risk to patient safety was accepted as the norm in some departments. The health board said work was under way to address the issues raised. The report was not an assessment of frontline care, but spoke to staff about procedures for reporting and learning from problems. It found Cwm Taf Morgannwg health board had not given enough attention to the safety of its services, in contrast to a strong focus on targets and financial controls. Read full story Source: BBC News, 19 November 2019
  17. Content Article
    There are a number of fundamental weaknesses in governance around patient safety and the quality of care at Cwm Taf Morgannwg University Health Board, a joint review by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office found. Following well-publicised concerns about maternity services at the Health Board, the joint review examined the organisation’s overall approach to quality governance. It found that whilst there has been a strong focus on financial balance and meeting key targets, less attention has been paid to the overall quality and safety of its services. The report highlights the need for stronger and broader leadership in respect of quality and patient safety and worryingly, points to a culture of fear and blame in some parts of the organisation that has prevented staff from speaking out and raising concerns.
  18. Content Article
    The Montgomery case in 2015 was a landmark for informed consent in the UK. Nadine Montgomery, a diabetic woman and of small stature, delivered her son vaginally; her son experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby's size was a potential problem. Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section The Supreme Court of the UK announced judgement in her favour in March 2015. It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told. This ruling means that patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics
  19. Content Article
    In the UK, each year over 1000 babies die or are left with severe brain injury, not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The Royal College of Obstetricians and Gynaecologists does not accept that all of these are unavoidable tragedies, and with the Each baby counts project, they are aiming to reduce this unnecessary suffering and loss of life by 50% by 2020.
  20. Content Article
    Maternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, this study from THIS.Institute focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.
  21. Event
    A multidisciplinary study day organised by the MASIC Foundation with leading speakers, reflecting the diverse professional roles required to coordinate and deliver effective and individualised care for women experiencing Obstetric Anal Sphincter Injury (OASI). Book tickets Consent Meeting 28th November 2019 (Patient Safety Learning Website).pdf
  22. Content Article
    Imperial College Healthcare NHS Trust maternity service provides care for around 10,000 babies and their mothers each year throughout pregnancy, labour, and the postnatal period. The Trust introduced the Cerner electronic patient record system including a maternity module for clinical documentation in 2014. Contractions and foetal and maternal heart rate are monitored using cardiotocograph (CTG) devices. Previously, the readings were printed out on rolls of paper. Midwives added handwritten clinical observations to these ‘foetal strips’ and used them to make critical decisions about the management of labour. These paper records were hard to share to quickly get a second opinion. They were prone to fading over time so did not always provide a permanent record and they were not integrated into the electronic patient records for our patients.
  23. Content Article
    Concern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
  24. Content Article
    Presentation from Mandy Townsend, Associate Director Patient Safety and co-lead for North West Coast Patient Safety Collaborative, at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
  25. Content Article
    For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience.
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