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News Article
'My baby died after I was ignored' - families call for NHS maternity inquiry
Patient Safety Learning posted a news article in News
When Tassie Weaver went into labour at full term, she thought she was hours away from holding her first child. But by the time she was giving birth, she knew her son had died. Doctors had previously told Tassie to call her local maternity unit immediately, she says, as she was considered high risk and needed monitoring, due to high blood pressure and concerns about the baby's growth. But a midwife told her to stay at home. Three hours later she called again, worried because now she couldn't feel her baby moving. Again, she was told to stay at home, the same midwife saying that this was normal because women can be too distracted by their contractions to feel anything else. "I was treated as just a kind of hysterical woman in pain who doesn't know what's going on because it's their first pregnancy," the 39-year-old tells us. When she called a third time, a different midwife told her to come to hospital, but when she arrived it was too late. His heart had stopped beating. Tassie and her husband John believe Baxter's stillbirth at the Leeds General Infirmary (LGI), four years ago, could have been prevented - and a review by the trust identified care issues "likely to have made a difference to the outcome". The couple are among 47 new families who have contacted the BBC with concerns about inadequate maternity care at Leeds Teaching Hospitals (LTH) NHS Trust between 2017 and 2024. As well as the new families, three new whistleblowers - two who still work for the trust - have shared concerns about the standard of care at its two maternity units - at the LGI and St James' University Hospital. This is in addition to the two we spoke to in the initial BBC investigation. Read full story Source: BBC News, 17 June 2025- Posted
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Angela Hayes, is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this blog, she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care: local screening for newborn developmental hip dysplasia supporting breast-feeding reducing health-inequalities for Albanian-speaking women. Background With births totalling over 673,000 in 2022, maternity services contribute significantly to the overall carbon footprint of the NHS, and therefore, to the environmental crisis. Pregnant women and infants are particularly vulnerable to climate change, which exacerbate existing health complications. Women from ethnic minorities or disadvantaged backgrounds are disproportionately affected so significant health inequalities persist. The Green Maternity Challenge was delivered in partnership with the Centre for Sustainable Healthcare, The Royal College of Obstetricians and Gynaecologists, The Royal College of Midwives and The Sustainable Healthcare. It aimed to: address the environmental impact of maternity care improve health outcomes create a more sustainable, equitable healthcare system. Nine clinical teams in the UK were chosen and supported by CSH to develop a Sustainable Quality Improvement project (SusQi) and measure its impact. Examples of impact Local screening for newborn developmental hip dysplasia - Orkney Due to geographical limitations, access to advanced equipment and specialist care and skills can be limited. Presently, families need to travel to Aberdeen with their newborns for the Ultrasound Newborn Screening for Hip Dysplasia. This has the potential to negatively affect clinical outcomes for patients, particularly those from peripheral areas such as Orkney Island, due to increased travel time and delay in travel owing to unpredictable weather, longer waiting periods and inconvenience to families. Local screening programmes can reduce waiting times and increase access to healthcare. It can also allow for early management and intervention in newborns. A team in Orkney introduced local screening facilities for newborn developmental hip dysplasia and eliminated the need for travel to the mainland. The programme has created increased job satisfaction for staff and reduced stress, travel and delays for patients. The environmental savings projected are around 22,500 miles and costs savings rising to £17000/year. Supporting breast-feeding - Great Western Hospitals NHS Foundation Trust Breastfeeding is important because it improves the long-term health of both mothers and babies. Between 74-86% of birthing people start breastfeeding in the first 48 hours. Around 8% stop breastfeeding by the time they go home from hospital and a further 20% stop during the first two weeks at home. There are several reasons for this, but a lack of infant feeding support is a major contributor. Lack of support also contributes to 5-20 mothers and babies a month requiring readmission for jaundice, weight loss and tongue tie. Staff on the post-natal ward at the Great Western Hospitals NHS Foundation Trust hoped to improve breast-feeding rates through the implementation of daily feeding support groups. They demonstrated improvements in effective person-centred care, staff satisfaction and patient confidence. With breast-feeding rates up by 5%, they projected yearly savings over £4600, reductions in re-admissions and outpatient appointments, and environmental savings equivalent to driving almost 5000 miles. Reducing health-inequalities for Albanian-speaking women - Kingston Vulnerable groups such as migrants and ethnic minorities, face various barriers in accessing healthcare, and as a result, face poorer clinical outcomes. One such example is that of Albanian speaking women in Kingston. Comprising of 1% of all maternity care bookings at Kingston (as compared to the 0.2% national population), Albanian women face various challenges such as language barriers, asylum seeking status, poor socio-economic status, lack of support, histories of human trafficking and sexual abuse, and pre-existing mental health conditions. They are also subject to discrimination and culturally insensitive care. All these factors contribute to underutilisation of healthcare services, limited access to high quality care, concerns about confidentiality as well as lack of faith in healthcare system. Delay in getting timely and appropriate care can lead to poorer health outcomes, often necessitating more intensive and resource heavy treatments. The Olive Clinic in Kingston & Richmond midwifery team arranged for an interpreter to support their ante-natal clinic for Albanian-speaking women to support them during and after pregnancy. Impact studies are yet to be measured but qualitative data shows encouraging results from women and midwives. Summary There are many more examples and case studies but these three particularly highlight how green initiatives can be aligned to patient safety improvements to make sure every newborn and every child receives safe care. With projected annual savings of £860,669, and carbon savings equivalent to 778,978 disposable nappies, they made a huge impact on sustainable and equitable maternity. Share your insights Do you have insights to share around balancing patient safety with sustainability? What are the challenges and opportunities? Contact the editorial team at [email protected] to share your ideas.- Posted
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Join this webinar on “Safe Birth and Neonatal Care – Strengthening Healthcare Systems for Every Newborn” on 13 June 2025, from 3:00 to 4:00 IST. This webinar aims to address system-level gaps in maternal and newborn care in India. The session will bring together healthcare professionals, policymakers, and patient advocates to discuss referral mechanisms, care standards, and strategies to improve outcomes for mothers and newborns. Focus Area: Safe care practices for newborns and children. Strengthening referral systems and delivery care. Reducing preventable maternal and neonatal deaths. System-level recommendations for safer healthcare. Join us to be part of this critical dialogue on advancing patient safety for every newborn and child. Register -
News Article
Manslaughter case launched into Nottingham baby deaths
Patient Safety Learning posted a news article in News
A corporate manslaughter investigation has been opened into failings that led to hundreds of babies dying or being injured at maternity units in Nottingham. Nottinghamshire Police said it was examining whether maternity care provided by the Nottingham University Hospitals (NUH) NHS trust had been grossly negligent. The trust is at the centre of the largest maternity inquiry in the history of the NHS, with about 2,500 cases of neonatal deaths, stillbirths and harm to mothers and babies being examined by independent midwife Donna Ockenden. The police investigation will centre on two maternity units overseen by the trust, which runs the Queen's Medical Centre and Nottingham City Hospital. NUH said it was "deeply sorry for the pain and suffering caused", and it was "absolutely right" that accountability was taken. In a statement on the force's website, Det Supt Matthew Croome, from the investigation team, said corporate manslaughter was a "serious criminal offence". He said: "The offence relates to circumstances where an organisation has been grossly negligent in the management of its activities, which has then led to a person's death. "In such an investigation we are looking to see if the overall responsibility lies with the organisation rather than specific individuals and my investigation will look to ascertain if there is evidence that the Nottingham University Hospitals NHS Trust has committed this offence." The force said its investigation into deaths and serious injuries related to NUH's maternity care - called Operation Perth - had seen more than 200 family cases referred to it so far. Read full story Source: BBC News, 2 June 2025- Posted
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External reviews ordered over trust’s baby death rates
Mark Hughes posted a news article in News
Two external reviews are being commissioned into maternity and neonatal care at the trust with the highest perinatal mortality rates. Leeds Teaching Hospitals Trust has claimed its extended perinatal mortality rate – which measures stillbirths and neonatal deaths – is within the expected range, considering it takes many high-risk pregnancies, including some where babies are not expected to survive, as a specialist centre. However, a report to its board meeting today reveals it is commissioning an external review of the issue. The review would examine mortality data. Read full article (Paywalled) Source: Health Service Journal, 29 May 2025- Posted
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Content Article
NHS Race and Health Observatory Review of Neonatal Assessment and Practice in Black, Asian, and Minority Ethnic Newborns highlighted the need for educational resources to help healthcare professionals assess babies with dark skin tones, who are at higher risk of developing jaundice and experiencing delayed diagnosis and treatment. This new infographic for health care professionals, “10 Steps to spot Jaundice in Black and Brown babies” was designed by Dr. Helen Gbinigie, Neonatal Consultant at Medway Hospital and Clinical Lead for KM LMNS; and Dr. Oghenetega Edokpolor, ST5 Paediatric Trainee at Medway Hospital, in collaboration with the NHS Race and Health Observatory. It’s a vital tool in pursuing the Observatory’s aims to reduce neonatal ethnic health inequalities.- Posted
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In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI. This blog is part of our World Patient Safety Day 2025 series - Safe care for every newborn and every child. Why was COMPASS developed? COMPASS was created based on work carried out by the Patient Experience Library who conducted a literature review of over 10 years’ worth of avoidable harm enquiries, which included the reports on the maternity services at East Kent and Morecambe Bay. The work has been collated into a report called ‘Responding to Challenge’¹. The review demonstrated that poor organisational culture is a recurrent theme in avoidable harm, with significant impact on patient safety. Their work highlights how organisational culture remains challenging to quantify and articulate which hampers external bodies’ ability to provide insight to providers. Through our safety investigations it became evident that MNSI did not have a way to record and analyse cultural observations in a structured and evidence-based format. This inhibited us from feeding back our observations to organisations to help them see how their organisational culture might be impacting on patient safety. What are the aims of COMPASS? We developed COMPASS for two key reasons: To provide MNSI staff with a standardised process to record observations around organisational culture, empowering MNSI staff to articulate their observations to trusts in a structured and evidence-based manner rather than based on personal experience or individual interpretation of certain situations. To highlight to trusts areas where their organisational culture is contributing positively to patient safety, and areas where enhancing their focus will support and improve safer care to be delivered. There is already significant work being done to help trusts to improve culture and leadership within maternity services, and COMPASS is a tool designed to complement this by focussing on how organisations respond to and learn from patient safety events. How is COMPASS being used? COMPASS is currently being piloted in partnership with 12 NHS trusts in England and is due to finish at the end of May. MNSI staff are using COMPASS to gather observations about organisational culture that may have impact on patient safety, in a structured manner that reflects the findings from the ‘Responding to Challenge’ report. The findings are then collated and reviewed to determine how frequently these types of observations are occurring so we can assess the overall level of impact to patient safety that may be occurring within each of the specific areas. These findings are then shared with trust leadership teams to flag areas that may require attention or focus to improve safety and organisational culture and also highlight observations of culture that have had a positive impact on patient safety. What is next for COMPASS? After the pilot, and with the help of feedback from both MNSI staff and trusts who piloted the report, we hope to: Adapt the COMPASS tool to match the needs of both MNSI and organisations we work with to maximise the impact of the tool. Showcase the positive impact COMPASS has had on patient safety within maternity and newborn services. Share our learning through the development of COMPASS and explore how this can be utilised in other sectors to improve patient safety across healthcare. If feedback suggests that the tool is of value to both MNSI and trusts, we may seek to use COMPASS on a regular basis to help share our insights into organisational culture with trusts to help improve patient safety. How can people find out more? Introducing COMPASS: A new safety tool to help understand the impact of culture on patient safety MNSI has launched a new patient safety tool COMPASS Red Flag Tracker – a tool to help recognise the red flags for harmful healthcare cultures by the Patient Experience Library References 1. The Patient Experience Library's Responding to Challenge report April 2025 Do you have a safety tool or project to share? Are you implementing a change that has had a positive impact on patient safety? Could you share your insights, tools and knowledge to help others? Or perhaps you are at the start of the journey, seeking ways to address a patient safety issue that you've identified. Comment below (sign up for free first) or contact our editorial team at [email protected] to tell us more. -
News Article
Delay in improving NHS maternity care ‘costs lives of hundreds of babies a year’
Patient Safety Learning posted a news article in News
A delay in improving NHS maternity care is costing the lives of hundreds of babies a year, analysis has shown. At least 2,500 fewer babies would have died since 2018 if hospitals had managed to reduce the number of of stillbirths and neonatal and maternal deaths in England, as the government falls behind on its commitment to halve the rate of those three events. That is according to a joint report by the baby charities Tommy’s and Sands, which assesses NHS progress on meeting targets that were set in 2015. Dr Robert Wilson, head of the Sands and Tommy’s joint policy unit, said: “Hundreds of fewer babies a year would have died since 2018 if the government had met its ambition to halve the rates of stillbirths and neonatal deaths in England by 2025.” The 2,500 deaths are “the equivalent of around 100 primary school classrooms”, Wilson said. The stubbornly high rates of stillbirth and neonatal death, despite efforts to tackle them, showed that ministers were doing too little to reduce the incidence of baby loss, Wilson claimed. He said: “The response from government and policymakers to the ongoing crisis in maternity and neonatal care and the scale of pregnancy and baby loss in the UK is simply not good enough. Too many people continue to suffer the heartbreak of losing a baby.” Read full story Source: The Guardian, 20 May 2025- Posted
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Each year since May 2023 the Sands & Tommy’s Joint Policy Unit have published an annual report setting out the extent of pregnancy and baby deaths across the UK. This year’s report argues that progress made to date falls short of what is needed to stop babies dying every day in the UK, and that unacceptable inequalities in pregnancy and baby loss persist despite continued calls for change. It estimates that at least 2,500 fewer babies – the equivalent of around 100 primary school classrooms - would have died since 2018 if the government had achieved its ambition of halving the 2010 rates of stillbirth, neonatal and maternal deaths in England. The report draws on the latest data from MBRRACE-UK, which shows that the gap continues to grow between neonatal death rates in the most deprived areas and those in the least deprived areas of the UK. It highlights that the stillbirth rate among babies of Asian ethnicity has risen sharply, and Black babies are still twice as likely as White babies to be stillborn. It includes 10 key actions for policymakers Renew commitments to save babies’ lives. Specifically, a stillbirth rate of 2.0 stillbirths, and a neonatal mortality rate of 0.5 neonatal deaths for babies born at 24 weeks’ gestation and over (per 1,000 live births). A preterm birth rate of 6.0%. Count miscarriages in the UK. The number and rate of miscarriages are not reported across the UK or for any individual nation. All UK governments should set up routine data collection on miscarriage. Take coordinated and meaningful action to eliminate inequalities. There are a range of policy areas where specific action is needed, including: understanding whether current efforts to reduce inequalities are working, and a comprehensive review of translation and interpreting services in maternity and neonatal care. Strengthen national leadership to make progress on the safety of maternity and neonatal services. Clarify the workforce needed to deliver safe care. Future development of the workforce must move away from a binary debate focussed on whether we do or don’t have enough staff and focus on the staffing requirements needed to deliver safe care, in line with nationally-agreed standards. Put the resources needed in place to deliver safe care. More investment is needed to improve the safety and quality of services if the government is going to deliver on its commitments to reduce rates of stillbirth and neonatal death and eliminate inequalities. Make informed choice a reality. Everyone should receive personalised care, know what they are entitled to, such as their birth choices, and services need the resources and operational capacity to provide this. Address unwarranted variation in care. Too often babies are dying because of care that is not in line with nationally-agreed standards. We need clarity on how national guidance is applied and clear national standards to improve the consistency of service provision. Ensure lessons are learned when babies die. The NHS is still not properly learning lessons when babies die or listening to the experiences of bereaved families to improve care in the future. There must be more robust oversight of the implementation of actions that are identified by reviews and investigations. Prioritise pregnancy and baby loss in research. This requires a broad range of research topics, the involvement of bereaved parents and communities, and a strong connection with policy and practice. -
News Article
Trust admits it ‘cannot safely run’ maternity service
Patient Safety Learning posted a news article in News
A trust is set to close one of its birthing units for at least six months after admitting it “cannot safely run” the service. Somerset Foundation Trust will temporarily close the maternity unit at Yeovil District Hospital “for an initial period of six months” from next week, amid significant gaps in medical staffing. The trust has said it “cannot safely run” the special care baby unit, which provides dedicated support for premature newborns, nor “safely provide care during labour and birth”. The closure follows concerns being raised by the Care Quality Commission. The regulator rated maternity services at Yeovil “inadequate” last year and also issued a warning notice in January after finding its paediatric care “requires significant improvement”. The CQC said the service did not have enough medical staff or emergency equipment to keep babies safe, and found not all staff followed infection control procedures. Dr Iles added that senior paediatricians from Somerset FT’s Musgrove Park Hospital are helping to ensure paediatric inpatient and outpatient services at Yeovil remain open, including obstetric and midwifery antenatal clinics, scanning, antenatal screening services, and home births. But she added: “We cannot care for any newborns who require care in a special care baby unit or safely provide care during labour and birth at the Yeovil maternity unit. “We are committed to providing safe, high quality, and sustainable services for those who need them, but we must address these concerns and need the time and space to do this. I apologise again to anyone who is affected by these changes.” Read full story (paywalled) Source: HSJ, 15 May 2025 -
News Article
Baby death NHS trust reaches 'turning point'
Patient Safety Learning posted a news article in News
Two maternity units in Kent have shown signs of improvements three years after a damning independent review found up to 45 babies might have survived if they had received better care, a report has said. The Care Quality Commission (CQC) report rated maternity services at William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate as good, two years after they were downgraded to inadequate. The CQC said "significant improvements" had been made at both units to safety, leadership, culture, the environment and staffing levels. Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, said the report was "an important milestone in our continuing work to improve our services". Serena Coleman, CQC's deputy director of operations in Kent, said: "We found significant improvements and a better quality service for women, people using the service and their babies. "This turnaround in ratings across both services demonstrates what can be achieved with strong and capable leaders who focus on an inclusive and positive culture." Kaye Wilson, chief midwife for the South East at NHS England, said: "This report marks a turning point for services at East Kent and is the result of the commitment, determination and sheer hard work of midwives, obstetricians and the whole maternity team." Read full story Source: BBC News,15 May 2025 -
News Article
New NHS programme to reduce brain injury in childbirth
Patient Safety Learning posted a news article in News
Expectant mothers will receive safer maternity care as a new NHS programme to help prevent brain injury during childbirth is rolled out across the country. The Avoiding Brain Injury in Childbirth (ABC) programme will help maternity staff to better identify signs that the baby is in distress during labour so they can act quickly. It will also help staff respond more effectively to obstetric emergencies, such as where the baby’s head becomes lodged deep in the mother’s pelvis during a caesarean birth. The government programme, which will begin from September and follows an extensive development phase and pilot scheme, will reduce the number of avoidable brain injuries during childbirth – helping to prevent lifelong conditions like cerebral palsy. The national rollout is only one step the government is taking to improve maternity services under its Plan for Change to fix the health service, as it reforms the NHS to ensure all women receive safe, personalised and compassionate care. Read full story Source: Department of Health and Social Care, 12 May 2025- Posted
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News Article
Earlier C-section could have saved baby
Patient Safety Learning posted a news article in News
A baby who died three days after birth would have survived if her mother had been offered a caesarean section, a coroner has said. Emmy Russo was delivered at Princess Alexandra Hospital in Harlow but died on 12 January 2024. Mother Bryony Russo told an inquest at Essex Coroner's Court that her requests for a C-section were "laughed off" during the hours she was there in labour. Assistant coroner for Essex, Thea Wilson, said there were five missed opportunities to offer Ms Russo a C-section, and that Emmy's chances would have been different had she been born an hour earlier. "She would have been born in a better condition and on the balance of probabilities she would have survived," she said. "There was a failure to respond adequately to the request for a C-section" Independent expert obstetrician Teresa Kelly had told the coroner there was enough evidence "this baby wasn't coping with labour" and staff should have acted sooner. Giving evidence, midwife Megan Fletcher defended her decision not to escalate concerns to a more senior doctor, saying she was trying to avoid any further "invasive procedures". Read full story Source: BBC News, 7 May 2025- Posted
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One by one, 29 women sat before Dr Laura Abbott in similarly small, nondescript rooms across five UK prisons, and described losing their babies. They were not bereaved in the conventional sense – although they were clearly holding in grief, as once the guards had left, they let rare public tears fall. Prisoners who had given birth in custody, they had been separated from their newborn children. In some cases this had happened within four or five days of becoming mothers. “It was worse than giving birth,” said one woman. “That was the hardest pain of my life. I’ve never felt pain like it … It was in my chest, in my heart. Even in my belly.” “It was as if my whole body craved him,” said another woman. “It’s like losing a limb, losing your sight,” a third explained. “It’s like losing any hope.” Some of the mothers were still producing milk when Abbott and her assistants spoke to them. One said she was so reluctant to raise this in the prison that she was expressing manually into her cell sink. Abbott, 54, a former midwife and senior lecturer in midwifery at the University of Hertfordshire, spoke to the women last year for the Lost Mothers Project, which will be launching at the British Museum in London on 8 May. A collaboration between the university, the charity Birth Companions and an advisory team of women with lived experience, the report, which is the result of three years of research, examines the experiences and needs of an invisible cohort. Anna (not her real name), 38, has endured this. She was six months pregnant when she was sent to prison nine years ago for her first offence. She was at full term when she finally stood before an MBU board. She is vocal about the horrors of giving birth in custody. She had to press her call bell “four or five times for an hour” when she felt labour pains. She says she was taken to hospital in handcuffs: “[The guard] told me to be grateful that she put me in long cuffs.” They were taken off before she was taken to the delivery suite – since 2022, it is mandated that restraints must not be used on pregnant women taken to appointments unless they are deemed essential. But it is when she talks about her subsequent separation from her son that Anna momentarily loses her words. She was initially granted an MBU place, but when bailed before sentencing she had to go back to the beginning, and needed to reapply when she returned to prison. This bureaucratic delay resulted in a five-week separation. Anna began to feel suicidal, and even stopped her mum bringing her son to visit. “It was just getting harder. Sometimes my legs felt heavy, as if they didn’t want to walk away,” she says. “Sorry, I’m getting upset …” She continues: “It was as if somebody was tearing my heart out.” Read full story Source: The Guardian, 6 May 2025- Posted
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This Independent Report led by Professor Mary Renfrew was commissioned in May 2023 by the Department of Health (DoH) Northern Ireland (NI). It forms part of a broad programme of work to receive assurance on the safety of maternity and neonatal services for the population of NI. It resulted from two related developments: A request from the Coroner for Northern Ireland that the Department of Health NI take action to investigate her concerns following an inquest into the death of a baby that raised questions about care in Freestanding midwifery led units (MLUs). In the inquest report the Coroner identified a number of practice and system failings and shortcomings including the management of shoulder dystocia, fetal macrosomia (the baby being large for gestational age), and raised maternal body mass index (BMI). At the time of the inquest, all Freestanding MLUs in NI were closed. The Coroner found that a comprehensive review of the number of staff, experience, training, and policies should be conducted by the DoH, in the event of these Units reopening in the future. In response to this request, the Permanent Secretary asked the Chief Nursing Officer (CNO) for NI, along with the Midwifery Officer, to instigate an inquiry into the issues highlighted by the Coroner. Several other reports, both local and national, concerning the safety of services for pregnant women, new mothers, and babies required consideration of the wider health service context that influences midwifery and maternity care and services. In summary, the report advocates for the following changes: A shared strategic vision for safe, quality midwifery and wider maternal and newborn services in Northern Ireland with a regional framework for action. A reconfigured relationship with women, families and communities, ensuring respectful personalised care for all and a genuine voice in shaping services. A consistent, region-wide, evidence-informed approach to planning, funding, standards, provision, monitoring, and review of maternity and neonatal services. Improving clinical, psychological, and cultural safety and equity for women, babies and families across the whole continuum of care and in all settings. Changing the prevailing work culture to implement an enabling environment for all staff and managers, including ensuring midwives are represented at senior management levels, tackling silo working, and developing an open learning culture at every level of the system. Supporting midwives to provide quality midwifery care and services across the whole continuum of maternal and newborn care, with investment in community as well as hospital services, and increasing midwives’ influence over the safety and quality of care and services. Better oversight through improved accountability, monitoring, evaluation, and research. A unified approach to education and training of all staff, including leadership development - especially for midwives - and capacity building for the future.- Posted
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Catch up on previous Maternity & Newborn Safety Investigations (MNSI) webinars and view slides from the presentations. Webinars and slide topics: Think beyond sepsis Sudden Unexplained Death in Epilepsy (SUDEP) First trimester deaths in England from venous thromboembolism associated with hyperemesis Maternal death from pulmonary embolism -
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Women today are more likely than ever to survive pregnancy and childbirth according to a major new report released today, but United Nations (UN) agencies highlight the threat of major backsliding as unprecedented aid cuts take effect around the world. Released on World Health Day, the UN report, Trends in maternal mortality, shows a 40% global decline in maternal deaths between 2000 and 2023 – largely due to improved access to essential health services. Still, the report reveals that the pace of improvement has slowed significantly since 2016, and that an estimated 260 000 women died in 2023 as a result of complications from pregnancy or childbirth – roughly equivalent to one maternal death every two minutes. The report comes as humanitarian funding cuts are having severe impacts on essential health care in many parts of the world, forcing countries to roll back vital services for maternal, newborn and child health. These cuts have led to facility closures and loss of health workers, while also disrupting supply chains for lifesaving supplies and medicines such as treatments for haemorrhage, pre-eclampsia and malaria – all leading causes of maternal deaths. Without urgent action, the agencies warn that pregnant women in multiple countries will face severe repercussions – particularly those in humanitarian settings where maternal deaths are already alarmingly high.- Posted
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Ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. These services act as the frontline responders, providing immediate care and facilitating timely transport to appropriate healthcare facilities. World Patient Safety Day, observed annually on 17 September, serves as a global platform to raise awareness about patient safety and encourage collaborative efforts to reduce harm in healthcare settings. The theme for 2025, 'Safe care for every newborn and every child', underscores the critical importance of safeguarding our youngest and most vulnerable patients from preventable harm. In the UK, ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. These services act as the frontline responders, providing immediate care and facilitating timely transport to appropriate healthcare facilities. Their contributions are multifaceted, encompassing emergency childbirth assistance, neonatal transfers and the management of obstetric emergencies. In addition, many women and families will use the 999/111 service throughout the childbearing continuum, often using these services as a gateway to accessing maternity care. A recent review of Maternity and Newborn Safety Investigations (MNSI) highlighted that 6 in 10 independent investigations that met the criteria for MNSI involved the ambulance service. Out-of-hospital births, though relatively rare, present unique challenges for ambulance clinicians. Intrapartum care accounts for approximately 0.05% of emergency medical services' caseload, with only about 10% of these cases resulting in deliveries managed by ambulance staff. This limited exposure can lead to a decline in obstetric clinical skills, potentially impacting patient care. To address this, continuous training and simulation exercises are essential. For instance, the London Ambulance Service has developed a bespoke communication tool to support midwives in out-of-hospital settings, ensuring effective communication during the transfer of women or babies in emergencies and delivers bespoke mandated emergency training to its frontline clinicians. Such initiatives enhance the preparedness of ambulance clinicians to manage emergency deliveries safely; however, these are not standardised across services. Challenges and areas for improvement Despite their critical role, UK ambulance services face challenges that can impact maternal and neonatal safety. Incidents of delayed response times have been reported, leading to tragic outcomes. For example, a three-day-old baby named Wyllow-Raine Swinburn passed away after an eight-minute delay in answering a 999 call and a 31-minute wait for the ambulance to arrive. Although the delays were not deemed the direct cause of death, they highlighted inefficiencies in the emergency response system. In other cases, the lack of effective training for ambulance clinicians impacted upon the management of a time critical breech delivery, with tragic consequences. Such cases underscore the need for systemic improvements, including better resource allocation, enhanced training and the implementation of robust protocols to minimise delays in emergency response. Collaboration between ambulance services and midwifery teams is essential for improving outcomes in maternal and neonatal emergencies. The development of communication tools and training programmes exemplifies efforts to standardise information exchange during emergencies, thereby reducing the potential for errors and delays. Furthermore, ambulance services are increasingly recognising the importance of specialised roles focused on maternity care. For instance, paramedics with additional training in neonatal and maternity care can provide more comprehensive support during emergencies. Susie, a paramedic with the Northwest Ambulance Service, highlighted her passion for improving maternity care within the ambulance service, emphasising the importance of continuous professional development in this area. Conclusion As we observe World Patient Safety Day 2025, it is imperative to acknowledge and support the vital role of UK ambulance services in safeguarding mothers and their newborns during and following pregnancy. Continuous training, effective communication tools and collaborative practices are essential to enhance the safety and quality of care provided. By addressing existing challenges and building on successful initiatives, we can move closer to the goal of ensuring safe care for every newborn and every child from the very start. Further reading Exploring the pre-hospital setting for the emergency care and transfer of neonates: the role of UK ambulance and neonatal transport services Displaced risk. Keeping mothers and babies safe: a UK ambulance service lens An exploration of maternity and newborn exposure, training and education among staff working within NWAS Disparities In Access to the Northwest Ambulance Service during pregnancy, birth and postpartum period and its association with neonatal and maternal outcomes World Patient Safety Day 2025- Posted
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USA: More Black babies are dying than white infants
Patient Safety Learning posted a news article in News
Although the disparity in the number of overall deaths reported between Black and white Americans has narrowed over the course of the last 75 years, researchers say that the same does not hold true for infants. Black infants are dying at twice the rate of white infants – and it’s largely thanks to healthcare inequality. “This is like a red alarm,” Harvard University associated professor Dr. Soroush Saghafian explained. “Our findings are saying: Look, we could have saved five million Black Americans if they had the same things as white Americans have,” he told The Harvard Gazette. The authors analysed mortality data collected by the U.S. Census Bureau and the Centers for Disease Control and Prevention, calculating life expectancy, mortality rates, and years of potential life lost for both white and Black Americas. Their analysis found that there was a 20.4 percent increase in life expectancy for Black Americans and a 13 percent rise for white Americans, although Black adults still have an 18 percent higher mortality rate. The American healthcare system has long been under scrutiny for its astronomical costs and hurdles to patient care. A new study released Wednesday from the West Health Institute has found that the inability to pay for healthcare in the U.S. has reached a new high. More than a third of Americans – or an estimated 91 million people – report that they could not access quality healthcare if they needed it, according to the latest West Health-Gallup Healthcare Affordability Index. Read full story Source: The Independent, 2 April 2025 -
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The Thirlwall Inquiry was set up to examine events at the Countess of Chester Hospital following the trial and subsequent convictions of Lucy Letby for the murder and attempted murder of babies at that hospital. This report was commissioned by the Thirlwall Inquiry. It summarises key themes from responses to a questionnaire sent by the Inquiry to all other NHS trusts with maternity and neonatal units in England. With the evidence and submissions phase of the Inquiry now closed, the Nuffield Trust publish it here in the form submitted to the Inquiry as of April 2024. Overarching themes For almost all the areas covered in the questionnaire there were existing regulations, mechanisms or guidance in place in the NHS. Within neonatal services there were additional reporting routes and requirements to take into account over and above those which apply across the NHS as a whole. In a small number of areas (for example use of CCTV) we found limited guidance. The infrastructure within trusts affected the processes they have in place to manage safety and risks. For example, there was variation between trusts in the availability of electronic systems to support access to medical records, medicines management and storage facilities, the maturity of systems for data collection, reporting and triangulating information, and ease of access to the ward for parents. However, policies, structures and processes on their own are not sufficient to ensure services are safe and effective. A wide body of research indicates that culture and leadership are critical, and a positive culture is needed for systems and processes to achieve their aims. Where there is variation in how trusts manage issues, this will reflect a combination of the circumstances of the organisation and the leadership approach to addressing issues. Some organisational circumstances are unique, but there are many factors affecting the whole NHS, or neonatal care specifically, for example resource and workforce pressures. Culture and leadership at an organisational level are also impacted by national leadership and management of the NHS. In some cases the quantity of guidance, reporting requirements, number of external regulators, and the frequency with which these change, leads to a risk that responding to external scrutiny takes precedence over learning and action within the organisation.- Posted
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CQC tells trust to move care of sick babies
Patient Safety Learning posted a news article in News
A trust has moved the care of some sick babies out of one of its neonatal units at the Care Quality Commission’s request. Leeds Teaching Hospitals Trust said babies requiring more than 24 hours of neonatal intensive or high dependency care would now be moved from St James’ University Hospital to the Leeds General Infirmary, which has a neonatal intensive care unit, or alternative hospitals. The trust confirmed this followed a request from the Care Quality Commission, which carried out unannounced inspections of its maternity and neonatal services in December and January. Previously St James’ had been providing “less complex elements of intensive care and high dependency care”, despite only having a “special care baby unit” (SCBU), which typically provides care for less seriously ill babies than a NICU. This unusual position had been agreed with the Yorkshire and Humber neonatal operational delivery unit. The trust said its neonatal doctors and nurses worked across the units in both hospitals, and were qualified and trained to treat babies requiring the highest level of care. The trust’s maternity services have recently been criticised by a group of parents, and HSJ last week highlighted how they have been rated “red” for high perinatal mortality in the national maternity services audit four times in the past seven years. Chief nurse Rabina Tindale said: “Individuals are still able to give birth at St James’ Hospital and babies will receive the appropriate level of care in our SCBU, but this [change] does mean that if babies need more than 24 hours of intensive care or high dependency care, they must be transferred to Leeds General Infirmary or another unit.” Read full story (paywalled) Source: HSJ, 1 April 2025- Posted
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Baby deaths trust claimed £2m 'good care' payments
Patient Safety Learning posted a news article in News
An NHS trust criticised over the avoidable death of a newborn baby was paid £2m for providing good maternity care, the BBC can reveal. A senior coroner ruled on Friday that University Hospitals of Morecambe Bay (UHMB) NHS trust contributed to Ida Lock's death and had failed to learn lessons from previous maternity failures. Despite this, the trust claimed it had met all 10 standards under an NHS scheme aimed at promoting safe treatment. Ida's mother Sarah Robinson said it was "another kick in the teeth" while her father Ryan Lock labelled it "disgusting". The trust, which has previously apologised for its failings in Ida's care, declined to comment about the NHS payment scheme. Senior coroner for Lancashire James Adeley concluded that Ida had died due to the gross failure of three midwives to provide basic medical care. Ida, who was born at the Royal Lancaster Infirmary (RLI) on 9 November 2019, died a week later after suffering a serious brain injury due to a lack of oxygen. Dr Adeley ruled her death had been caused by the midwives' failure to deliver the infant "urgently when it was apparent she was in distress" and contributed to by the lead midwife's "wholly incompetent failure to provide basic neonatal resuscitation". He said eight opportunities had been missed "to alter Ida's clinical course". Read full story Source: BBC News, 26 March 2025- Posted
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Baby slings unsafe for hands-free feeding, charities warn
Patient Safety Learning posted a news article in News
Childbirth charities are warning parents that hands-free breastfeeding or bottle feeding, when a baby is being carried in a sling, is unsafe. The National Childbirth Trust (NCT) and the Lullaby Trust say the risks are highest for premature babies and those under four months old because their airways can be easily blocked. Their updated guidance follows an inquest into the death of a six-week-old boy who was being breastfed in a baby carrier while his mother moved around their home. The baby, Jimmy Alderman, from London, was being breastfed in a sling in October 2023, but was in an unsafe position too far down the sling and lost consciousness after five minutes, the coroner found. A coroner's report to prevent future deaths like his found there was very little information on safe positioning of babies in slings or the risks of suffocation when feeding. Senior coroner for west London, Lydia Brown, issued a warning, external about the dangers of baby slings following an inquest held last year into his death. She said there appeared to be no helpful visual images of "safe" versus "unsafe" postures for babies in slings or carriers, adding that "the NHS available literature provides no guidance or advice". The NCT said it "immediately reviewed" its online information on baby slings and carriers after receiving the coroner's report and hearing feedback from Jimmy's parents. The NCT's online advice now says: "Hands-free breastfeeding or bottle feeding, where the wearer moves around and does other jobs while the baby is feeding, is unsafe. "This is especially true for babies under four months old. It also applies to babies born prematurely or those with a health condition." The charity says young babies do not have strong necks and cannot lift their heads, meaning that their airway "can easily be blocked" in baby slings and carriers. It adds that a sling's fabric or the fabric from a parent's clothes "could cause suffocation very quickly". "If the sling or carrier is not correctly fitted and adjusted, babies can experience traumatic head injuries," the charity's advice says. Read full story Source: BBC News, 26 March 2025- Posted
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It has now been more than a year since plans for a compensation scheme were laid out for those affected by the sodium valproate scandal—and it is a state failure that stretches back decades. Sodium valproate is an effective treatment for epilepsy, but it has been linked to lifelong disabilities in around 20,000 babies born since the 1970s whose mothers were prescribed the drug while they were pregnant. Many were not properly warned of the risks, and a 2020 review concluded that thousands of mothers and babies had been exposed to "avoidable harm". In opposition, Labour said that financial redress for victims was "desperately needed" - so why has nothing happened since the party took office? And how much longer will those families be forced to wait? Related reading on the hub: A year on from The Hughes Report: Urgent action needed on redress- Posted
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By the entrance to Furness General Hospital in Barrow-in-Furness sits a sculpture of a moon with 11 stars. It is a memorial to the mother and babies who died unnecessarily due to poor care at the hospital between 2004 and 2013. When the memorial was unveiled in 2019, Aaron Cummins who is chief executive at University Hospitals of Morecambe Bay NHS Trust, which runs the hospital, said: "We will never forget what happened. We owe it to those who died to continually improve in everything that we do." Barely a month later, Sarah Robinson stepped into a birthing pool at the Royal Lancaster Infirmary, a hospital run by the same NHS trust. She was about to give birth to her second child. Within an hour, Ida Lock was born; within a week, she was dead. The inquest into Ida Lock's death, which concluded last week, exposed over five weeks why maternity services across England have long struggled to improve - and this one case holds a mirror to issues that appear to be prevalent across a number of trusts. 'That investigation, carried out by Dr Bill Kirkup and published in March 2015, found there had been a dysfunctional culture at Furness General, substandard clinical skills, poor risk assessments and a grossly deficient response to adverse incidents with a repeated failure to properly investigate cases and learn lessons. Morecambe Bay became a byword for poor maternity care and the trust promised to enact all 18 recommendations from the Kirkup review. And yet that never happened. Ida Lock's inquest began last month, more than five years after she died - the delay was down to several reasons, including its particular complexity. What emerged was just how profoundly many of those lessons had not been learned. Particularly egregious, says Ms Robinson, was a suggestion from a midwife – shortly after the birth - that Ida's poor condition was linked to her smoking, something Sarah had never done in her life. As the coroner found on Friday, Ida's death was wholly avoidable, caused by a failure to recognise that she was in distress prior to her birth, and then a botched resuscitation attempt after she was born. By the time she was transferred to a higher dependency unit, at the Royal Preston hospital, she had suffered a brain injury from which she could not recover. Having failed to deliver their daughter safely, Ida's parents would have expected that the trust would properly and openly investigate her death. Instead, they pursued an investigation that Carey Galbraith, the midwife who completed it, would later describe as "not worth the paper it was written on". They didn't take responsibility for their failings despite having an independent report from the Healthcare Safety Investigation Branch (HSIB). Clearly, the Morecambe Bay report was not, as was hoped, a line in the sand for maternity services across England, or a rallying cry for widespread improvements. As the inquest has shown, it did not even lead to sustained improvement at Morecambe Bay. Read full story Source: BBC News, 24 March 2025 Further reading: Ida Lock: Baby girl died from brain injury because midwives failed to provide basic care, coroner rules- Posted
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