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Found 31 results
  1. News Article
    Following the Advanced cyber attack in August 2022, Phil Huggins has revealed to a Digital Health Rewired audience that the NHS has “seen no clinical impact or significant clinical harm”, after a review to be released in the near future. The national chief information security officer for health and care at NHS England was speaking alongside a panel on the Cyber Security Stage on day two of Digital Health Rewired 2023 in London. Huggins explained that although the impact of the Advanced attack was big on the system, in a clinical sense it was not particularly damaging, despite the fact that client data was confirmed to have been exfiltrated. However, Ayesha Rahim, clinical lead for digital mental health at NHS England and chief medical information officer at Surrey and Borders Partnership Foundation Trust, was also on the panel, and spoke of the huge impact the attack had on staff. “The date 4th August is imprinted in my brain”, Rahim said, which is when the attack first happened and was first reported. She explained that it is “quite difficult to fully convey the chaos this caused”, giving examples of staff having no idea what a patient’s background was and therefore having to do everything “blindfolded”. Rahim said staff could not tell if it was safe to go out on visits to mental health patients due to the lack of data and information on them, and every time a person saw a staff member they were retraumatised having to explain their past over and over, including experiences of sexual abuse. Read full story Source: Digital Health, 15 March 2023
  2. News Article
    More than three years into the Covid pandemic, there are a host of important unanswered questions about Long Covid, which significantly limit healthcare providers’ ability to treat patients with the condition, according to US physicians and scientists. That vacuum of information remains as much of the US has moved on from the pandemic, while Covid long-haulers continue to face stigma and questions over whether their symptoms are real, providers say. “We don’t quite have our finger on the pulse of what’s wrong, what biologically is causing it, and that’s a big problem,” said Dr Marc Sala, co-director of the Northwestern Medicine Comprehensive Covid-19 Center. “It’s hard to direct drugs or treatments without having the biological underpinnings for why someone is feeling so fatigued with exercise.” In addition to the ambiguity around the root causes of Long Covid, there are also challenges in research because of how Covid can produce so many different symptoms. The Centers for Disease Control and Prevention list includes fatigue, respiratory issues and difficulty thinking or concentrating but also states that “post-Covid conditions may not affect everyone the same way”. “Everyone has a different constellation of symptoms,” said Dr Steven Deeks, an infectious disease specialist at the University of California, San Francisco. “Some people get better over time, some people wax and wane, some people get worse,” and so it is difficult for researchers to determine when a study should end and compare a drug versus a placebo. Read full story Source: The Guardian, 6 March 2023
  3. Content Article
    Changes in the way staff work, including staff taking on new roles and responsibilities, is a well-known policy solution in the NHS, and there are some really good instances where skill mix works well and has real benefits. But are there downsides to the drive to employ new types of staff to help doctors and nurses? What are the implications for continuity of care, staff experience and outcomes? Is the idea of ‘top of the licence’ working a reason for concern in terms of burnout, the fragmentation of care or is it an unavoidable response to the workforce crisis? Chair: Nigel Edwards, Chief Executive, Nuffield Trust Prof Alison Leary, Chair of Healthcare and Workforce Modelling, London South Bank University Dr Louella Vaughan, Senior Clinical Fellow, Nuffield Trust
  4. Content Article
    In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, 4 January 2023) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
  5. Content Article
    Jenny, my mother Jenny was a much-admired mother, grandmother and friend. She had a strong determination and an uplifting zest for life; she was loyal and we, her family, miss her. Her passions were many, from her love of travel to places of geographic interest, to line-dancing and amassing a curious Tupperware collection. Jenny attended university in the 1960s, a time when women from her background were discouraged from attending further education. Having graduated, Jenny then worked for British Leyland and later moved to Germany with my father where she taught English. During which time she had me. Jenny returned alone with me to England in 1985, to no home or job. Her ability and determination ensured she quickly got a teaching role, then a home – she subsequently taught GCSE and A-Level for 27 years at Lewes Old Grammar School, living in the Brighton area that she called home. Unfortunately, my mother, Jenny, passed away prematurely from a pulmonary embolism in February 2022 following misdiagnosis. I am seeking to help derive a positive learning from her death and, unfortunately, many other similar recent cases. While she was 74, an extra 5 or 10 years would have made a great difference to our family – it has deprived my mother of time with her first grandchild, my daughter, who was born just weeks earlier in January 2022. A catalogue of errors taking away valuable years’ left of life Jenny, my mum, should likely not, medically speaking, have passed away on Sunday 27 February 2022 of a pulmonary embolism – a blood clot in her vein passing to her lung causing heart failure. Studies indicate that the death rate for diagnosed and treated pulmonary embolism is 8%.[1] She had never smoked in her life, exercised regularly and all had appeared well with her health at the start of 2022. She had received a letter from her GP granting her travel insurance that would have allowed her to travel to the Greek Islands and, later in the year, to the Baltic countries. In early February, despite exhibiting risk factors and sudden symptoms, including fainting and collapse, my mother was wrongly misdiagnosed in the care of an emergency department as having had a heart attack. She was then needlessly fitted with a stent. Upon her discharge from hospital her condition got worse again at home – she was dying – and yet she was reassured by a cardiac nurse who, over the phone, missed the signs of shortness of breath, chest pain (in the centre of the chest) and of fainting. The nurse advised that if the symptoms continued that my mother should call her GP. My mother never made her GP appointment. I don’t want this to continue to happen to other family’s loved ones. This was entirely avoidable. Jenny was waiting in A&E for over 12 hours and there were nine independent decision-making points where at any one of these, pulmonary embolism could and should, in totality, have been diagnosed. Pulmonary embolism was only discovered in an autopsy, and yet she exhibited symptoms consistent with 90% of pulmonary embolism patients.[2] A lack of learning forcing me to act Upon my complaint to the NHS trust that oversaw my mother’s care, a Serious Incident Report was commissioned by the trust and an inquest set up. However, in my opinion, the NHS trust appears to have exhibited a ‘shrug of the shoulders, these things happen conclusion’, inhibiting sufficient learning from my mother’s case. NHS England’s 2015 Serious Incident Framework was in operation at the time of the trust’s Serious Incident Report,[3] encouraging hospital trusts to appoint independent reviewers to ensure objectivity. However, the subject-matter experts chosen to contribute to the report were all involved with the original care of my mother and, hence, objectivity of the report was lost. The frustration I feel at the loss of my mother has then been compounded by the intransigence of the NHS trust that oversaw my mother’s case, and then the discovery that my mother’s case was not alone. Indeed, far from it. Image: Tim with his wife and little girl. References Belohlavek J, Dytrych V, Linhart A. Pulmonary Embolism, Part I: Epidemiology, Risk Factors and Risk Stratification, Pathophysiology, Clinical Presentation, Diagnosis and Nonthrombotic Pulmonary Embolism. Experimental and Clinical Cardiology 2013: 18; 129-138. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC), 2008. NHS England. Serious Incident Report Framework, 2015. Read the recently published, independent report Tim authored: Independent Review of Pulmonary Embolism fatalities in England & Wales - recent trends, excess deaths, their causes and risk management concerns Further reading Press release (Patient Safety Learning) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
  6. Content Article
    Key findings from the report: There were 400 excess deaths attributable to pulmonary embolism misdiagnosis from March 2021 to April 2022 in England and Wales. In parts of England and Wales the number of deaths due to pulmonary embolism were almost 3 times the national average. The clinical guidelines and diagnostic processes used in England and Wales are out of step with our European counterparts and, in Jenny’s case, were not used correctly. Clinical teams too often lack the training, expertise and/or equipment to deliver safe and effective pulmonary embolism care. Commenting on the report, Tim Edwards said: "My research found that there are hundreds of people who, like my mother Jenny, died from pulmonary embolism following misdiagnosis. It's vital we learn from these deaths, and the errors that have occurred, so we can take action to improve pulmonary embolism care. By publishing this report, I hope to start a dialogue that leads to positive change, so others do not suffer the loss of a loved one as we have." Helen Hughes, Chief Executive of Patient Safety Learning said: “This new report highlights serious patient safety concerns relating to the diagnosis of pulmonary embolisms. Urgent action is now needed to ensure that guidelines and diagnostic processes are up to date and that clinicians have the resources they need to deliver safe and effective care. It is also vital that we increase awareness of the key symptoms of pulmonary embolisms among both healthcare professionals and the wider public. Patient Safety Learning are proud to be supporting Tim and his campaign for improvement in pulmonary embolism care and to reduce avoidable deaths.” Calls for action The report includes nine calls for action to improve pulmonary embolism care: 1 Raise the level of suspicion for pulmonary embolism – given a surge in PE-related deaths, greater awareness amongst frontline emergency department and other clinicians of the importance of considering the possibility of PE during their diagnostic decision-making. More general training alongside specialisms and simulation to support practice and development of decision-making skills. Could the NEWS scoring system be calibrated to consider the aggregate of scores over a 5-6 hour period is one area for further discussion. 2 Buy-in for clinical guidelines - clinical guidance is only as valuable as, firstly, its validity and there is evidence that the NHS is not applying pulmonary embolism guidance considered best practice in comparable European countries and, secondly, adherence, which is evidenced as inconsistent at best and worst, ignored. This report calls for a change, not just a review, of NICE clinical guideline NG158 covering pulmonary embolism diagnosis. 3 Avoidance of high-risk appetite - to achieve operating standards and meet financial incentives, risk appetite should not be a variable that can be compromised or amended. A compliance metric tracking whether clinical guidelines were successfully followed could be included as a diagnostic tool used as part of the Get it Right First Time (GIRFT) initiative 8 to ensure CTPA scanning for pulmonary embolism is not under-used. 4 Ensure radiology departments have the appropriate resources - so they can deliver a safe and effective service. Currently 41% of clinical radiologists do not have the right equipment 3 and the levels of scanners is less than half that in France and a quarter of that in Germany. There are also personnel shortages. There needs to be a plan in place to address these shortages. 5 National consistency, compliance and risk management - exploration of the underlying causes of regional variation, whether from differentials in resources or processes. Ensure oversight approaches/audits are suitably embedded within existing clinical governance systems. 6 Patient engagement - meaningful engagement with those affected when carrying out an incident investigation to ensure family members’ expertise is harnessed and that they are treated as partners in the learning response (where they so wish), not just in setting the terms of reference. 7 Independence - while independent authors may contribute to investigations, independent subject-matter experts are not always involved therefore undermining the integrity of any report conclusions. NHS England’s 2015 Serious Incident Framework guidelines require independent contributors to ensure objectivity and so clearly there may need to be a review of how 'contributors' is defined and how this process may better ensure lessons are being suitably learnt. 8 Knowledge sharing – effective, timely dissemination of learning from a serious incident investigation carried out in one organisation across the NHS to other organisations which may experience a similar type of PE misdiagnosis incident in the future. Ensure Clinical Knowledge Summaries providing the latest research and clinical findings are sufficiently disseminated and actioned by frontline emergency department and clinical staff in a timely fashion. 9 Public awareness – extension of existing awareness campaign advising those at risk of the symptoms to look out for and when to seek medical attention You can access the report in full via the attached PDF document below. Further reading House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)
  7. Content Article
    My mother, 87 years, was admitted to hospital with a suspected heart attack. At the time, she was on a strong dose of a GP-prescribed opioid (fentanyl) to manage her growing lung cancer. The Duty doctor in the hospital seemed panicked as she was so unwell and used a drug to totally reverse her morphine as they thought she had overdosed. This caused excruciating pain for most of the last 60 hours of her life. They hadn’t properly assessed the history of her prescription or asked me, her documented health advocate, about the drug or my mother’s end of life wishes. After a 2-year long traumatic journey for the family, the Inquest issued a Prevention of Future Deaths report, agreeing her prior medication should have been properly assessed. After another year and a convoluted journey through the health system, NHS England’s Patient safety team issued a National Safety Alert to all English hospitals around more careful use of pain relief reversing. Five years later, my good friend was on an unusual cocktail of GP-prescribed drugs for her very painful arthritis. She was admitted to hospital after a fall that dislocated her severely arthritic shoulder. For three days in hospital she went through different medical teams, but no one looked at her pain control needs or her unusual medication, and the only pain relief medication that had worked for her for years was removed totally from very early on in the admission. She suffered on those hard hospital beds, unable to move to a comfortable position due to her painful arthritis, lack of adequate pain control and her shoulder that remained painfully dislocated. She could not move on those beds without help. She was in agony for three days. Sadly she died of a pulmonary embolism in hospital in the midst of that traumatic experience. What both these people have in common is the neglect of their medically prescribed, carefully designed pain control to meet their unique needs, their understandable wishes and personal rights. As a result their essential pain control was totally removed while other necessary medical interventions occurred. These patient and service user’s rights were not respected. Huge suffering resulted. This I believe needs addressing and learning from. Pain control needs of patients with chronic conditions needs to be carefully assessed and addressed on all hospital admissions from the very start of admission. The current complaint and Inquest systems do not have as their agenda these types of safety learning. There are two routes whereby these incidents can be recorded, with one route that may lead to an investigation and system learning nationally. One is the NHS patient portal, which is just for reporting (no one will get back to you, but the information you share could be used to improve safety for future patients), and the other is the Healthcare Safety Investigation Branch (HSIB) who do national investigations almost always on recently occurring events. I would add there are developments in patient safety learning, including patient safety partners rolling out across some health facilities, but this is relatively early on in a national process: https://www.england.nhs.uk/patient-safety/framework-for-involving-patients-in-patient-safety/ The new NICE guidance on Shared Decision Making also adds to the pressure to learn and change from cases like this. Perhaps special guidance is needed for those admitted for emergency care with complex palliative medication needs? I hope a Body will take this up soon. The patient, service user, family and carer voice must be heard and acted on to improve patient safety at these difficult times. If you or anyone you know has had an experience like this, particularly in the last few months, do let me know by emailing me or commenting on this post below, as the routes above could lead to long lasting learning. It is sorely needed.
  8. Content Article
    Key findings Local host responses to polypropylene (PP) used in surgical mesh included pain, foreign body sensation, seroma and haematoma. When PP mesh was used in other surgeries (female stress urinary incontinence mesh or mini-sling, transvaginal or transabdominal prolapse mesh), the primary local responses were erosion/exposure followed by dyspareunia and pain. Studies reported these complications from immediately post surgery to five years post surgery. Evidence suggested that lightweight PP mesh was less likely than heavier weight PP mesh to cause pain or foreign body sensation. There were no studies elucidating patient– or material-related factors contributing to systemic responses. ECRI’s data pointed to infection in 40% of event reports associated with PP mesh. There were five deaths, and when patient harm was reported, 44% required intervention or hospitalisation. Evidence gaps The report identifies the following evidence gaps: Studies of local and systemic host response to PP as a material. Studies examining local or systemic host response to diaphragmatic hernia mesh. Better quality evidence regarding local responses such as inflammation, mesh migration, and pain and regarding systemic responses to mesh such as allergy, autoantibody development and systemic inflammation.
  9. Event
    Health First Europe and the members of the European Patient Group on Antimicrobial Resistance are glad to invite you to our Parliament Roundtable Debate entitled “Engaging with patients and closing knowledge gaps to fight antimicrobial resistance: the role in infection prevention and antimicrobial stewardship.” The event will take place in a hybrid format on Thursday 27 October, 10:00-11:30 CEST (9:00-10:30 BST), kindly hosted by MEP Ondřej Knotek (Renew Europe, Czech Republic), and under the patronage of the Czech Presidency of the Council. Join us to learn more about how AMR affects patients across Europe and how everyone can take action to prevent the development of resistant bacteria. Please register as soon as possible to secure a spot in the European Parliament or to join the conference remotely! We hope you’re able to join us. Register for the event
  10. Content Article
    These four vlogs are edited versions of vlogs originally commissioned by the NHS. They are all fully referenced based on UK National Institute for Health and Care Excellence (NICE) guidelines and on the Royal Pharmaceutical Society Prescribing Competency Framework for all prescribers (see the video description) and contain links to useful sources of further information. Shared decision making - 'It's my decision', which covers the latest NICE Guideline on shared decision making. 'Too much information' - Dealing with information overload on medicines & prescribing, which includes some of the work of the former UK National Prescribing Centre on information mastery. The way numerical data presentation influences decisions and treatments. Key components of taking a past medical history and a thorough medicines history when prescribing, which is a refresher on what was covered in the Independent Prescribing Course.
  11. Content Article
    HSIB was notified about potential patient safety issues by Sarah, who was concerned about the care she had received when her babies were delivered. The investigation used interviews, observations of the maternity unit and reviews of guidelines and organisational documents in order to understand the system-wide factors that contributed to Sarah’s experience and the decisions made by staff. The evidence suggested that the process of decision making in the context of Sarah’s care was relevant to this investigation, so the investigation has summarised the key factors that appear to have influenced the decision making associated with her care and the delivery of her babies Findings There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies. There are gaps in scientific knowledge and challenges to completing research in the field of preterm labour and birth. This creates a challenge for the development of detailed guidelines to support clinical decision making. Guidelines and equipment recommended for managing and monitoring singleton (one baby) and full-term pregnancies are used to assist with clinical decision making about preterm twin pregnancies; some interventions within the guidelines are unproven for use in preterm twin pregnancies. Research and national improvement initiatives, such as the British Association of Perinatal Medicine perinatal optimisation care pathway and NHS England and NHS Improvement ‘Saving babies’ lives care bundle version two’ and the Maternity and Neonatal Safety Improvement Programme are improving the standardisation and implementation of evidence-based interventions. Intelligence from national data gathered by maternity units can support the learning on preterm labour and birth in twin pregnancies. Safety observations It may be beneficial if further research aimed to generate additional knowledge to predict and prevent preterm labour for twin pregnancies among different groups of women/pregnant people. It may be beneficial to increase awareness among the public and healthcare professionals of the limitations of interventions for the prevention of preterm labour of multiple births. It may be beneficial to regularly analyse data on multiple births so the interpretation of this data can inform learning and research. Safety actions Following stakeholder feedback received during an update of the guideline for preterm labour and birth, the National Institute for Health and Care Excellence decided to delete the recommendation relating to milking the cord and amend the subsequent recommendation on clamping of the cord to wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping.
  12. Content Article
    Morris et al. concluded that the current state of knowledge of time lags is of limited use to those responsible for R&D and knowledge transfer who face difficulties in knowing what they should or can do to reduce time lags. This effectively ‘blindfolds’ investment decisions and risks wasting effort. The study concludes that understanding lags first requires agreeing models, definitions and measures, which can be applied in practice. A second task would be to develop a process by which to gather these data. Further reading: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  13. Content Article
    What can I learn? Introducing power of the patient Tricky conditions: understanding disease, diagnosis and decisions What everyone should know about getting the best care The patient's side of the call for better
  14. Content Article
    It is 22 years since the publication of To Err is Human and An Organisation with a Memory. Patient Safety has become a priority worldwide with the passing of the WHO Global Action Plan on Patient Safety. Almost every country has a plan or set of interventions to decrease harm and make healthcare safer. And the development of the science of patient safety has been exponential with increasing evidence of what is required to be safe. We now know what we need to do to prevent harm. In the report led by Sir Liam Donaldson it was stated that four actions were needed to improve safety in the NHS: unified reporting an open culture mechanisms for change a systems approach to solving the challenges of patient safety. Twenty-two years on this challenge remains only partially fulfilled. As is reported in the recent Patient Safety Learning's Mind the implementation gap - The persistence of avoidable harm in the NHS, there is a major problem of taking the lessons from incidents and implementing them at scale so that processes can be changed. The report highlighted four themes, focusing mainly on the lack of a systems approach to safety, learning, oversight monitoring and evaluation, and a lack of leadership. If we are to be safe in the future there must be a fundamental change to the way we think about safety, and the need to incorporate both improvement and implementation science in addressing the implementation gap. There are many reasons for the gap in applying what we know to what we do. This is not uncommon in healthcare where new knowledge takes time to percolate to frontline staff and applies to clinical theory as well as to patient safety theories and methods. So while we may state that we need a systems approach and leadership, we cannot expect frontline staff to be safe if they do not have easy access to the latest theories and methods on patient safety. I believe that to make a difference we need to equip every healthcare worker with the knowledge and skills to be safe. From that frontline revolution we can then look at having a safer NHS in which safety is what we do every day, not what we do only after harm has occurred. This includes learning from everyday practice and constantly asking ourselves “what do we need to do to be safe?” The Oxford University Press Handbook of Patient Safety aims to bridge the knowledge gap so that the implementation gap can be narrowed and eventually closed. The book has been written by a combination of experts in the field of patient safety science and frontline staff, i.e. people who practice safety every day and know what it takes to be safe. The book translates the complex patient safety theories into actions that frontline staff can take to be safe. We hope that the book will make a difference in changing the paradigm and that it becomes the daily companion of every healthcare professional in the NHS. Knowledge is the driver of change and will make a difference. The Oxford Professional Practice: Handbook of Patient Safety is available at the discounted price here.
  15. Community Post
    We should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909