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Content ArticleThis World Health Organization (WHO) guideline aims to improve the quality of essential, routine postnatal care for women and newborns with the ultimate goal of improving maternal and newborn health and well-being. It recognises a “positive postnatal experience” as a significant end point for all women giving birth and their newborns, laying the platform for improved short- and long-term health and well-being. A positive postnatal experience is defined as one in which women, newborns, partners, parents, caregivers and families receive information, reassurance and support in a consistent manner from motivated health workers; where a resourced and flexible health system recognises the needs of women and babies, and respects their cultural context. This is a consolidated guideline of new and existing recommendations on routine postnatal care for women and newborns receiving facility- or community-based postnatal care in any resource setting.
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Content ArticleThis is the transcript of a statement given in the House of Commons by the Secretary of State for Health and Social Care, Sajid Javid MP, in response to the publication of the final report of the Ockenden Review. In the statement he makes a commitment that the local trust, NHS England and the Department of Health and Social Care will accept all 84 recommendations made by the Review. This is followed by questions from MPs in the Chamber and Mr Javid's responses.
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In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).- Posted
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Content ArticleThe Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
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Content ArticleThis blog provides an overview of a roundtable webinar organised by the European Biosafety Network (EBN), which focused on the need to prevent exposure to hazardous medicinal products (HMPs) and other substances. It was chaired by Gitta Vanpeborgh, Belgian Federal Deputy, and included attendees from across Europe.
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Content ArticleA woman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae. Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice. This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation. The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area.
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WHO: Abortion care guidelines (9 March 2022)
Patient Safety Learning posted an article in Women's health
The World Health Organization (WHO) has released new guidelines on abortion care in a bid to protect the health of women and girls and help prevent over 25 million unsafe abortions that currently occur each year around the world. Based on the latest scientific evidence, these consolidated guidelines bring together over 50 recommendations spanning clinical practice, health service delivery, and legal and policy interventions to support quality abortion care. When carried out according to WHO guidelines, abortion is a simple and safe health intervention. The new guidelines will support access to comprehensive and quality abortion care within national health systems in the WHO European Region and globally. -
Content ArticleIn this episode of the Institute of Economic Affairs (IEA) Podcast, IEA Head of Political Economy Dr Kristian Niemietz discusses the findings of the Independent Medicines and Medical Devices Safety Review, and how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices. Kristian speaks with Simon Whale, panel member and communications lead for the Independent Medicines and Medical Devices Safety Review and Dr Sonia Macleod, lead researcher, Independent Medicines and Medical Devices Safety Review. They discuss how the NHS, and other health bodies, could improve their services to address poor care and prevent harm.
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Content ArticleThe West Suffolk Review, commissioned by NHS England on behalf of the Department for Health and Social Care, was published last month. NHSE/I asked the West Suffolk Board to produce an action plan for the 28 January meeting of the Board of Directors. This paper summarises the current position in relation to the learning, reflection and response thus far, including the organisational development actions that have already been taken and require further embedding. It also highlights the engagement undertaken to date, and what more needs to happen, to ensure our plans are based on the priorities for staff, governors, patients and teams and can carry the confidence of stakeholders. The report, 'West Suffolk Review – organisational development plan (p. 217)', sets out nine broad themes of work, linked to the trust’s core functions, “that capture the priority areas for organisational and cultural development at WSFT in light of the learnings from the report”. The document sets out how the trust’s governance, freedom to speak up, HR, staff voice, patient safety and other parts of its corporate infrastructure failed and contributed to a scandal.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 28 February 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by Sodium Valproate.
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Content ArticleA report looking at how the government can lock in the lessons of the COVID-19 pandemic to build a more robust, sustainable and joined-up system of social care.
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HSIB Maternity newsletter (May 2021)
Patient Safety Learning posted an article in HSSIB investigations
HSIB is pleased to present the first quarterly newsletter sharing learning from trusts across the whole of England. The purpose of this newsletter is to allow clinical teams and trusts to share the changes that have been made as a result of the findings and recommendations from maternity investigations undertaken by the Healthcare Safety Investigation Branch (HSIB). These initiatives were developed by the trusts and their maternity teams, we would like to thank them for sharing their work with others. This approach to collaborative learning supports trusts to share resources and improvement ideas that relate to similar concerns each trust experiences, as they strive to continually improve the care and safety of mothers and their babies. These examples of learning reflect what is being implemented in trusts with varying requirements to support their maternity services. This allows what is learnt in Newcastle to be known about in Penzance. -
Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the management of patients with COVID-19 being treated with non-invasive respiratory support, for example continuous positive airway pressure (CPAP), in non-critical care settings. The HSIB investigation reviewed the experience of Terry, who was admitted to hospital with symptoms of COVID-19 and required support with is breathing using CPAP. On the second day after his admission to hospital, Terry was found on the floor next to his bed, having called for assistance. Terry’s CPAP tubing had become disconnected from his mask, meaning that Terry’s breathing was not supported. Staff attempted to resuscitate Terry, however they were unsuccessful, and he died.
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Content ArticleThe need for radical investment and reform of diagnostic services was recognised at the time the NHS Long Term Plan was published in 2019. This report, commissioned by NHS England at that time, alongside a review of adult screening services, was nearing publication before the COVID-19 pandemic struck. However, while the recommendations made pre-pandemic still stand, additional actions will be needed to deliver safe, high quality diagnostic services in an endemic phase of the disease and to support the recovery of diagnostic services.
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Content ArticleLast week the Professional Standards Authority for Health and Social Care published a new report, Reshaping regulation for public protection, outlining their view on the implications of the Health and Care Bill for professional regulation.[1] In this blog, Patient Safety Learning looks at this report in more detail and explores the key patient safety aspects of this.
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Thought piece on the Ockenden Report by Susan Stanford
Patient Safety Learning posted an article in Maternity
People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Many of the recommendations in the Ockenden report were already covered by national guidance, Susan Stanford asks why the guidance wasn’t followed and whether it might not be being followed elsewhere. -
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House of Commons Debate - NHS Allergy Services (29 October 2021)
Mark Hughes posted an article in Allergies
This is the transcript of an Adjournment Debate from the House of Commons on the 29 October 2021 on NHS Allergy Services, tabled by Jon Cruddas MP. -
Content ArticleNICE has published its updated guideline on the diagnosis and management of myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome (ME/CFS). It is estimated that there are over 250,000 people in England and Wales with ME/CFS, with about 2.4 times as many women affected as men. The guideline covers every aspect of ME/CFS in children, young people and adults from its identification and assessment before and after diagnosis to its management, monitoring and review.
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Content ArticleThe All Party Parliamentary Group for Allergy, in conjunction with the National Allergy Strategy Group (NASG), has launched a new report which calls for the appointment of an influential lead for allergy who can implement a new national strategy to help the millions of people across the UK affected by allergic disease. This report brings to Ministers’ attention the growing allergy epidemic and the lack of NHS services for people with allergic disease. 20 million people in the UK, a third of the population, are living with allergic disease with five million of these severe enough to require specialist care yet our allergy services remain inadequate, often hard to access and are failing those who need them the most. Change is required and is now long overdue. For the growing number of people living with allergic disease in the UK, their condition can have a significant and negative impact on their lives. It is frightening and restrictive to live with a condition which could cause a severe or life threatening reaction at any time.
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Content ArticleThe purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) is to help improve patient safety in relation to the care of patients who have NHS-funded surgery in an independent hospital. This was initiated in the context of the COVID-19 pandemic, where because of increased pressure on the NHS, independent hospitals have been providing more care for NHS patients, including urgent elective surgical care and delivery of cancer pathways. The HSIB investigation reviewed the experience of a patient with a diagnosis of bowel cancer, who was booked to undergo laparoscopic (keyhole) surgery to remove part of his bowel in in an independent hospital. Following surgery, the patient made slow progress and on day eight following surgery he started to deteriorate rapidly. He was transferred to the local NHS hospital for investigation and further surgery. He died later the same day as a result of sepsis following a complication of his recent surgery.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on the 21st October 2021, which notes disappointment with the UK Government’s response to the Independent Medicines and Medical Devices Safety Review. The motion calls on the Government to reconsider its response and to implement all nine recommendations in their entirety, and to ensure patient safety remains paramount in any changes to regulatory approval frameworks.
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Content ArticleThis document provides guidance for maternity services and Local Maternity Systems on how to develop a local plan for achieving Midwifery Continuity of Carer as the default model of care offered to all women. The guidance sets out recommended practice, how delivery against these plans will be assured nationally, and how provision will be measured at provider and Local Maternity System level. Midwifery Workforce Tools designed to help midwifery leaders safely plan, simulate and design maternity services can be used alongside this guidance.
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Content ArticleThis is the first in a series of thematic reports which will be published by the Independent Maternity Services Oversight Panel in the coming year. The purpose of the report is to summarise the learning which is emerging from the ongoing programme of independent clinical reviews of the maternity and neonatal care previously provided by the former Cwm Taf University Health Board. This particular report summarises the key themes and issues which emerged from the clinical review of 28 individual episodes of care1 which were provided by the Health Board between 01 January 2016 and 30 September 20182. It focuses on the care of mothers who needed unplanned emergency treatment during childbirth, including some who required admission to an Intensive Care Unit.
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This is the second in a series of thematic reports to be published by the Independent Maternity Services Oversight Panel about their ongoing programme of independent clinical reviews of the maternity and neonatal care provided by the former Cwm Taf University Health Board. This report focuses on the care of mothers and their babies who were stillborn. It summarises the key themes and issues which emerged from the clinical review of 63 individual episodes of care which were provided by the Health Board between 01 January 2016 and 30 September 2018. -
Content ArticleThis review in the World Journal of Nephrology assesses the value of clinical audit in nephrology settings. It looks at areas where the use of clinical audit has been effective, such as hypertension and mineral metabolism control in haemodialysis patients. The authors suggest ways to make the process effective and recommend that clinical audit is used more widely within the field of nephrology.
