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Rachel Hardeman has dedicated her career to fighting racism and the harm it has inflicted on the health of Black Americans. As a reproductive health equity researcher, she has been especially disturbed by the disproportionately high mortality rates for Black babies. In an effort to find some of the reasons behind the high death rates, Hardeman, an associate professor at the University of Minnesota School of Public Health, and three other researchers combed through the records of 1.8 million Florida hospital births between 1992 and 2015 looking for clues. They found a tantalising statistic. Although Black newborns are three times as likely to die as White newborns, when Black babies are delivered by Black doctors, their mortality rate is cut in half. "Strikingly, these effects appear to manifest more strongly in more complicated cases," the researchers wrote, "and when hospitals deliver more Black newborns." They found no similar relationship between White doctors and White births. Nor did they find a difference in maternal death rates when the doctor's race was the same as the patient's. Read full story Research paper Source: The Washington Post, 9 January 2021

In a Letter to the Editor published in The Times yesterday, the All Party Parliamentary Group on First Do No Harm Co-Chair Baroness Julia Cumberlege argues in favour of the work of the Independent Medicines and Medical Devices Safety (IMMDS) Review and its report 'First Do No Harm'. "Inquiries are only as good as the change for the better that results from their work." Read full letter (paywalled) Source: The Times, 5 January 2021

All NHS trusts in England have been given a deadline of Monday to enact safety improvements in maternity care amid Shropshire's baby deaths scandal. Heath chiefs have told hospitals they must have the 12 "urgent clinical priorities" in place by 17:00 GMT. The move is to address "too much variation" in outcomes for families. It comes during a probe into the maternity care of more than 1,800 families in Shropshire. The inquiry, launched amid concerns of repeated failings at Shrewsbury and Telford Hospital NHS Trust (SaTH), focuses on the experience of 1,862 in total, and includes instances of infant fatality. An interim report published last week found poor care over nearly two decades had harmed dozens of women and their babies. The report called for seven "essential actions" to be implemented at maternity units across England. But that has since been transformed into 12 clinical tasks, including giving women with complex pregnancies a named consultant, ensuring regular training of fetal heart rate monitoring, and developing a proper process to gather the views of families. The directions are revealed in a letter in which NHS England says there is "too much variation in experience and outcomes for women and their families". Read full story Source: BBC News, 15 December 2020

Strong leadership, challenging poor workplace culture, and ringfencing maternity funding are key to improving safety. That’s the message from two leading Royal Colleges as they respond to the independent review of maternity services at Shrewsbury and Telford NHS Trust led by Donna Ockenden. The RCOG and the Royal College of Midwives (RCM) have today welcomed the Ockenden Review and its recognition of the need to challenge poor working relationships, improve funding and access to multidisciplinary training and crucially to listen to women and their families to improve learning and to ensure tragedies such as those that have happened at Shrewsbury and Telford NHS Trust never occur again. The Colleges have said that the local actions for learning and the immediate and essential actions laid out in this report must be read and acted upon immediately in all Trusts and Health Boards delivering maternity services across the UK. Commenting, Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said: “This report makes difficult reading for all of us working in maternity services and should be a watershed moment for the system. Reducing risk needs a holistic approach that targets the specific challenges of fetal monitoring interpretation and strengthens organisational functioning, culture and behaviour." Read press release Source: RCOG, 10 December 2020

Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/

The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report

Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth. The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth. Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life. In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage. The new funding will also cover the final year of the independent investigation into the Shrewsbury trust. Read full story Source: The Independent, 26 November 2020

Former health secretary and chair of the Commons health committee Jeremy Hunt has criticised Great Ormond Street Hospital after it was accused of covering up errors that may have led to the death of a toddler. Writing for The Independent, Mr Hunt, who has set up a patient safety charity since leaving government, said it was “depressing” to see how the hospital had responded to the case of Jasmine Hughes, which has now been taken to the Parliamentary Health Service Ombudsman for a new investigation. Mr Hunt said the hospital had chosen to issue a “classic non-apology apology of which any politician would be proud” and added he was left angry over the hospital’s “ridiculous decision” to stop talking to Jasmine’s family and the refusal to apologise for what went wrong. The MP for South West Surrey said the case was symbolic of a wider problem in the health service of a blame culture that prevents openness and transparency around mistakes. Read full story Source: The Independent, 24 November 2020

A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020

A coroner has urged ministers to revisit plans to make it possible to hold inquests into babies that are stillborn after a baby died due to “excessive force” during an attempted forceps delivery. Senior coroner Caroline Beasley-Murray has written to the Ministry of Justice after she was forced to stop hearing evidence into the death of baby Frederick Terry, known as Freddie, who died under the care of the Mid and South Essex Hospitals Trust on 16 November, last year. An inquest into his death was started in September where Freddie was found to have died after suffering hypovolaemic shock as a result of losing a fifth of his blood when his skull was fractured during a traumatic birth attempt. In a report on the case the coroner said: “Baby Frederick Joseph Terry was delivered by caesarean section, after a failed forceps attempted delivery on 16 November 2019 and death was confirmed after 40 minutes of resuscitation attempts." "The evidence showed that baby Freddie's very serious scalp and brain injuries were sustained during the failed forceps attempted delivery and, but for these, baby Freddie would have survived as a perfectly formed, healthy baby." The coroner said the injuries he sustained implied “an excessive degree of force” in the application of the forceps, which are curved metal instruments that fit around a baby’s head and are designed to help deliver the baby. The inquest had to be stopped from hearing any more evidence because coroners are not able to investigate stillborn babies. As part of her report, the coroner said: “It would have been helpful for there to have been, during the course of the inquest, an exploration, in the course of evidence, of the treatment and care provided to baby Freddie and his parents at the time of delivery. "Currently there is no legislation to cover the holding of a coroner’s inquest into a stillbirth. In March 2019, the Government issued a consultation on coronial investigations of stillbirths It would be helpful for this important topic to be progressed, whatever the ultimate jurisdictional decisions.” Read full story Source: The Independent, 17 November 2020

Mothers are being needlessly separated from their babies under strict hospital restrictions introduced to stop the spread of COVID-19, doctors and charities have warned. The measures preventing UK parents from staying with their babies when one or both require hospital treatment are causing trauma and increasing the risk of physical and mental health problems, it is claimed. Some parents of sick babies are also being barred from seeing their child in neonatal units, which is causing distress and preventing bonding. Campaigners have written to the health secretary, Matt Hancock, to raise their concerns. They want hospitals to review these policies urgently and have called for a working group to draw up national standards to meet families’ needs during pregnancy, birth and breastfeeding. Read full story Source: The Guardian, 16 November 2020

Lockdown measures in England led to thousands fewer children receiving vital immunisations for a range of diseases include measles, diphtheria and whooping cough, Public Health England (PHE) has warned. PHE has warned parents they should continue to get their children immunised regardless of lockdown and restrictions brought on by coronavirus. During the first wave of coronavirus the government advised that children should continue to receive vaccinations as scheduled but despite these some appointments were delayed and the numbers of children vaccinated against common diseases fell compared to 2019. PHE looked at data from almost 40% of GP surgeries for use of the common 6-in-1 vaccination for diseases including diphtheria, tetanus, whooping cough, and polio as well as uptake of the measles, mumps and rubella (MMR) vaccine to 19 October. In total 167,322 children had the 6-in-1 vaccine, a drop of 6,600 on the same period in 2019, a fall of almost 4%. A total of 167,670 children had the MMR jab, 4,700 fewer than in 2019, a drop of 2.8%. Although the vaccinations recovered after lockdown the rates are still lower overall than 2019. Dr Mary Ramsay, head of immunisations at Public Health England, said: “Vaccines remain the best defence against infection. It’s essential we maintain the highest possible uptake to prevent a resurgence of serious and sometimes life-threatening diseases. “Routine vaccinations are still available throughout the pandemic – it’s vital that we continue to make it as easy and safe as possible for parents to take their children to appointments.” Read full story Source: The Independent, 11 November 2020

A nurse is due in court charged with eight counts of murder following an investigation into baby deaths at the Countess of Chester hospital neonatal unit in Cheshire. Lucy Letby, 30, is due to appear at Warrington magistrates court on Thursday. She was arrested for a third time on Tuesday as part of the investigation into the hospital, which began in 2017. A force spokesman said: “The Crown Prosecution Service has authorised Cheshire police to charge a healthcare professional with murder in connection with an ongoing investigation into a number of baby deaths at the Countess of Chester hospital.” He said Letby was facing eight charges of murder and 10 charges of attempted murder relating to the period from June 2015 to June 2016. On Tuesday, police said parents of all the babies involved were being kept fully updated on developments and were being supported by officers. Read full story Source: The Guardian, 11 November 2020