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Key findings Almost everywhere in the world, a child born today has a better chance at surviving to age 5 than in 1990, but inequities persist among and within countries Divergent chances of survival start from the earliest ages Globally and across all regions, the probability of dying between the ages of 5 and 24 is lower than for children under 5 years old, yet more than 2 million children, adolescents and youth aged 5—24 died in 2021 -
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Coroner's concerns During the course of the investigation the evidence revealed matters giving rise to concern. If the coroner is inhibited from being in a position to confirm the cause of death of a baby, there is a risk that future deaths will occur unless action is taken. Matters of Concern The placenta, a key organ required for a full paediatric post mortem in an early neonatal death, has been interfered with such that the Paediatric Pathologist, is limited in his conclusion as to the likely cause of death. In some ways the placenta is akin to an organ for the purposes of a- Posted
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News Article
Hospital apologises after hiding surgeon's error for seven years
Patient Safety Learning posted a news article in News
A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section. For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame. "It was just continuous lies," the 34-year-old told BBC News. East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned". Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust whi- Posted
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News Article
Concern voiced over 'unacceptably high level' of births by caesarean section
Patient Safety Learning posted a news article in News
The rising number of women who have caesarean sections instead of natural births is causing concern for the National Childbirth Trust (NCT). The trust, which supports women through pregnancy, childbirth and early parenthood, says it does not know why the rate of caesareans is increasing. One in four maternity services showed a caesarean rate of between 20% and 29.9%, and 2% of services had a rate of more than 30%, according to latest figures. The World Health Organization recommends that the acceptable rate is 10 to 15%. The maternity care working party, a multi-disciplinary gro -
News Article
Water jabs and burning herbs offered during natural births at NHS hospitals
Patient Safety Learning posted a news article in News
Mothers are being offered water injections by the NHS to relieve pain during childbirth, while in some hospitals midwives are burning herbs to encourage breech babies to turn in the womb. Safety campaigners have dubbed the practices dangerous and say that they amount to “pseudoscience” being offered by the health service. They have called on the chief executive of NHS England, Amanda Pritchard, to ban their use in a letter published over the weekend. At least three trusts in England offer water injections for pain relief, including Newcastle upon Tyne Hospitals Trust, United Lincolns -
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The study found that duration of surgery and epidural drug used were both significant risk factors of breakthrough pain during CS in this audit. A pro-active policy is required in order to prevent breakthrough pain or discomfort during CS. Early identification of problematic epidural catheters for labour analgesia, adequate level of anaesthetic block before surgery, and administration of a prophylactic epidural top-up if duration of surgery is prolonged as opposed to the choice of local anaesthetic used, could be essential in the prevention. Further high-quality studies are needed to evaluate -
News Article
Death of three-day-old baby ‘avoidable’, coroner rules
Patient Safety Learning posted a news article in News
The death of a three-day-old baby could have been avoided if medical professionals had acted differently, a coroner concluded. Rosanna Matthews died three days after being delivered at Tunbridge Wells Hospital in Kent in November 2020. The hospital trust apologised, saying the level of care for Ms Sala and her daughter “fell short of standards”. Ms Sala told the inquest midwives were "bickering" and appeared confused during her labour. She claimed that if she had been allowed to start pushing when she wanted to, instead of waiting as midwives advised, Rosanna would have liv -
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C-section delay left baby severely disabled
Patient Safety Learning posted a news article in News
A baby was left "severely disabled" after a delay during his delivery by Caesarean section, a High Court judge has been told. Betsi Cadwaladr health board will pay £4m in compensation after a negligence claim was brought by one of the boy's relatives. He has required 24-hour care since his birth in 2018 at Glan Clwyd Hospital in Denbighshire. The hospital apologised, saying doctors are "working hard" to learn lessons. "We are extremely sorry," barrister Alexander Hutton KC, representing the health board, told Mr Justice Soole. "[Betsi Cadwaladr] is working hard to lear -
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Coroner's concerns and recommendations Concern 1 X was recruited as a locum registrar by the Hospital Trust without there appearing to have been any assessment of his skills and abilities or any supervision of him at the hospital. This was not an emergency appointment after, for example, a doctor calling in sick at the last minute. X gave evidence that the recruitment, assessment and supervision of locums is a national problem and that there is a need for a review on a national level. This raises concerns that there may be a risk to other lives both at this trust and at other trust- Posted
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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 -
News Article
Women wait days for induced labour in troubled maternity service
Patient Safety Learning posted a news article in News
A troubled acute trust has been sent a further warning notice after inspectors found severe shortages of midwives were causing dangerous delays to labour inductions. During one day in June, the Care Quality Commission found eight high-risk women at Blackpool Victoria Hospital had waited prolonged time periods for their labour to be induced. They said one woman had waited five days, while another who was forced to wait more than two days despite her waters having broken on the ward. Delays to labour induction can lead to serious safety risks for mothers and babies. The hospital’s -
News Article
‘Difficult discussions’ as NHS faces shortage of childbirth pain relief
Patient Safety Learning posted a news article in News
The NHS has been hit by a shortage of epidural kits to give mothers-to-be, a key form of pain relief during childbirth, as well as the drug that women are offered as an alternative. Supplies of epidural kits and the painkiller Remifentanil are now under such pressure that some hospitals cannot offer pregnant women their usual right to choose which one they want to reduce labour pains. Anaesthetists have told the Guardian that the simultaneous shortage of both forms of pain management has led to “difficult discussions” with women who had been told during their antenatal care that they- Posted
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Giving birth in England is considered very safe. But it doesn’t mean we can’t do more, and it doesn’t mean we should only look at mortality. There are other questions we need to be asking: What kind of start are we giving mothers? Do they feel safe giving birth? Do they feel safe in pregnancy? Do they feel safe in those first few weeks and months looking after that tiny new person? Motherhood is hard. Looking after mothers so that they can take good care of their babies makes good sense, so maybe looking after those who are caring for mothers makes good sense too? The Royal College- Posted
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News Article
Language around birth should be less judgemental, midwives' report says
Patient Safety Learning posted a news article in News
The language used around childbirth should be less judgemental and more personal, a report led by midwives has found. Most women consulted said terms such as "normal birth" should not be used, it says. The report recommends asking pregnant women what language feels right for them. Maternity care has been under the spotlight after a recent review found failures had led to baby deaths. The new guidance "puts women's choices at its heart, so that they are in the driving seat when it comes to how their labour and birth are described", Royal College of Midwives chief executive G- Posted
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Royal College of Midwives: Re:Birth summary report 2022
Patient Safety Learning posted an article in Maternity
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Senegal midwives convicted over mother's death
Patient Safety Learning posted a news article in News
Three Senegalese midwives involved in the death of a woman in labour have been found guilty of not assisting someone in danger. They received six-month suspended sentences, after Astou Sokhna died while reportedly begging for a Caesarean. Her unborn child also died. Three other midwives who were also on trial were not found guilty The case caused a national outcry with President Macky Sall ordering an investigation. Mrs Sokhna was in her 30s when she passed away at a hospital in the northern town of Louga. During her reported 20-hour labour ordeal, her pleas to doctors to c -
News Article
Baby death mother 'was not seen by obstetrician'
Patient Safety Learning posted a news article in News
A woman whose baby died after sustaining severe brain damage during labour was not seen by an obstetrician during her pregnancy, an inquest heard. It meant his mother Eileen McCarthy was unable to discuss her birthing options. Walter German was starved of oxygen during a long labour at the Royal Sussex County Hospital in Brighton. Lawyers at Fieldfisher are pursuing a civil negligence case, claiming a C-section should have been offered due to a previous third-degree tear. Walter was born in December 2020. His life-support was turned off after nine days, as his injuries were unre- Posted
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The report highlights specific threats to health for pregnant women and new mothers with young children, for example: stress and poor nutrition affecting the growth of an unborn baby and subsequent difficulties breastfeeding swelling and skin conditions from having to wash clothes by hand pelvic pain from climbing multiple flights of stairs health impacts such as rashes and asthma in young children that had resulted from poor housing conditions, including damp. It also draws attention to serious failings where policies in place to promote and protect maternal he- Posted
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