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News Article
Change to sepsis advice after mums' herpes deaths
Patient Safety Learning posted a news article in News
Advice on how new mothers with sepsis should be treated is to change after two women died of a herpes infection. The Royal College of Obstetricians and Gynaecologists says viral sources of infections should be considered and appropriate treatment offered. This comes after the BBC revealed one surgeon might have infected the mothers while performing Caesareans on them. The East Kent Hospitals Trust said it had not been possible to identify the source of either infection. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died of an infection caused by the herpes virus 44 days apart -
News Article
Jailed women in UK five times more likely to suffer stillbirths, data shows
Patient Safety Learning posted a news article in News
Women in prison are five times more likely to have a stillbirth and twice as likely to give birth to a premature baby that needs special care, new data collected by the Observer shows. Following two baby deaths in prisons since 2019 there have been increasing concerns about safety for pregnant women and their babies. Figures obtained through freedom of information requests made to 11 NHS trusts serving women’s prisons in England show 28% of the babies born to women serving a custodial sentence between 2015 and 2019 were admitted to a neonatal unit afterwards – double the national fig -
News Article
UK health trusts suspend home birth services as midwives shortage deepens
Patient Safety Learning posted a news article in News
A severe shortage of midwives has led to home birth services being closed or reduced by a number of hospital trusts across the UK, with pregnant women frequently left in limbo as to where they will be able to give birth. The Observer has found more than 20 trusts that have had disrupted home birth services in the past three months. Eight confirmed their services remain suspended due to staff shortages. They include East Kent Hospitals, Swansea Bay University Health Board and NHS Dumfries and Galloway – all of which report that the situation is under constant review. Home birth servic -
Content Article
Birthrights video: Speak Up, Speak Out (16 November 2021)
Patient-Safety-Learning posted an article in Maternity
In the video, three women tell their stories of poor care experiences in labour and after birth. They talk about racial discrimination, procedures that were done to them without their consent, and not being listened to when they knew they needed help. They highlight the importance of complaints in helping services improve. Suggested reading Birthrights Factsheet -
News Article
Black women four times more likely to die in childbirth
Patient Safety Learning posted a news article in News
Black women are more than four times more likely to die in pregnancy or childbirth than white women in the UK, a review of 2017-2019 deaths shows. The MBRRACE-UK report found women from Asian backgrounds are almost twice as likely to die as white women. Some 495 individuals died during pregnancy or up to a year after birth, out of 2,173,810 having a child. The charity Birthrights is concerned that overall "this bleak picture has not changed in over a decade". University of Oxford researchers say for the vast majority of people, pregnancy remains very safe in the UK. But des -
Content Article
Delay in recognising placental abruption (30 June 2021)
Patient-Safety-Learning posted an article in Maternity
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News Article
Pandemic changes affected maternity care for women who had stillbirths
Patient Safety Learning posted a news article in News
Changes to maternity services during the pandemic, including the mandatory redeployment of midwives and doctors to care for infected patients, may have affected the care given to women who had stillborn babies, a Healthcare Safety Investigation Branch (HSIB) investigation has found. The safety watchdog launched an investigation after the number of stillbirths after the onset of labour increased between April and June 2020. During the three months there were 45 stillbirths compared to 24 in the same period in 2019. The HSIB launched a probe examining the care of 37 cases. Among its fi -
Content ArticleSafety recommendations HSIB made eight safety recommendations as a result of this investigation, five to NHS England and NHS Improvement, one to the Royal College of Obstetricians and Gynaecologists, one to NHSX, and one to DHSC. HSIB recommends that future iterations of the Royal College of Obstetricians and Gynaecologists’ guidance clarify the management of a reported change in fetal movements during the third trimester of pregnancy with due regard to national policy. HSIB recommends that NHS England and NHS Improvement leads work to develop a process to ensure consistency
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Content Article
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Content ArticleRadio 2 episode (1h:09m:42s into the episode) Further reading: BMJ: Vaginal examinations, consent and COVID-19 (May 2020) Birthrights: How to run a safe and rights respecting maternity service during a pandemic
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News Article
'Gross failure in care' of baby starved of oxygen
Patient Safety Learning posted a news article in News
There was a "gross failure in basic care" which led to a baby being starved of oxygen during birth, a coroner said. Zak Ezra Carter died at the Royal Gwent Hospital, Newport, two days after being born in July 2018 at Ystrad Fawr Hospital in Caerphilly county. Gwent coroner Caroline Saunders said the monitoring of Zak and his mother Adele Thomas fell "well below the standards expected". She said she was reassured the health board had taken steps to improve care. Ms Thomas told the Newport hearing she felt "scared" and staff "didn't care" when she arrived to give birth on 20 July -
News ArticleWhen pharmacist Ifeoma Onwuka, known to her friends as Laura, went into hospital to have her daughter, she and her husband hoped the delivery would go smoothly, and that they would soon be able to take their new arrival home to meet her siblings. Onwuka's labor was induced at James Paget University Hospital in Great Yarmouth in late April 2018. Things progressed quickly and there were soon signs that her baby was in distress, causing staff to begin preparations for an emergency Caesarian section, but Onwuka's daughter was born in the recovery room. Shortly after the birth, Onwuka's
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News Article
Health secretary to investigate allegations of women denied epidurals
Patient Safety Learning posted a news article in News
Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony. Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader. An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE). Mr Hancock said all expectant mothers should be -
News ArticleHospitals have been refusing requests for caesarean sections during the COVID-19 outbreak despite official guidance and NHS England advice that they should go ahead. Multiple NHS trusts have told women preparing to give birth since March that requests for a caesarean section will not be granted due to the viral pandemic. It has led to accusations from the charity Birthrights that the coronavirus outbreak is being used as an excuse to promote an ideology that more women should have a natural birth. Maria Booker, from Birthrights, told The Independent: “We continue to be contacted
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News Article
Expectant mothers turn to freebirthing after home births cancelled
Patient Safety Learning posted a news article in News
When Victoria Gianopoulos-Johnson got a call from her midwife to say her home birth would be cancelled, panic took hold. She says she “lost it” for two days, crying constantly, gripped by uncertainty and then anger. Now she has reached the decision to have a free birth, also known as unassisted childbirth. Maternity rights groups say there has been a rise in the number of women seeking advice about freebirthing owing to pressures on hospitals and new restrictions around birth partners. More than a fifth of birthing centres and more than a third of homebirth services have closed due t -
News ArticleRachel 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 stat
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Content ArticleAs a result of the investigation, one recommendation has been made to the Care Quality Commission (CQC) on assessing factors such teamwork and psychological safety in its regulation of maternity units. Based on the evidence gathered, the report also sets out a series of questions to consider in order to help staff identify strengths and opportunities for improvement within their own maternity unit. Safety recommendation It is recommended that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary t
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News ArticleMore women may suffer pain due to being conscious while undergoing caesareans or other pregnancy-related surgery under general anaesthetic than realised, a troubling new study has found. The report, conducted by medical journal Anaesthesia, found being awake while having a caesarean is far more common than it is with other types of surgery. Researchers discovered that one in 256 women going through pregnancy-related surgery are aware of what was going on — a far higher proportion than the one in every 19,000 identified in a previous national audit. If a patient is conscious at
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News Article
Pregnant women must be respected by medics, says regulator
Patient Safety Learning posted a news article in News
Mothers-to-be must be respected and listened to by medics, regulators have said, after warnings that pleas for pain relief in labour have been ignored. The intervention by the Nursing and Midwifery Council (NMC) follows an investigation by The Sunday Telegraph. Last week it was revealed that six NHS trusts were in breach of medical guidance which says pain relief should be provided at any point of labour if it is requested. Women said they were told “‘It’s not called labour for nothing, it’s meant to be hard work” as doctors refused their pleas. The findings prompted the Health Secre -
News ArticleA coroner has today slammed a hospital for a series of serious failings after a mother bled to death when a medic refused to allow her vital clotting products. Gabriela Pintilie, 36, from Grays, Essex, gave birth to her healthy baby girl, Stefania, in February last year following a C-section after a long labour. But she suffered a major haemorrhage and died from a cardiac arrest hours later. Basildon University Hospital, in Essex, came under fire after it emerged a locum haematologist refused to give Mrs Pintilie the blood after he followed the wrong set of guidelines. The fresh froz
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Content Article
Unicef UK Baby Friendly Initiative has updated its policy guidance in the light of these investigations and some organisations are using posters and checklists to help staff understand and carry out their responsibilities. HSIB has also observed the impact of high task load, environment and staffing levels on the ability of staff to detect SUPC. Recommendations Maternity services should consider the following learning observations to ensure safe delivery of skin-to-skin care. • Based on the evidence, a baby who is born apparently well, with good Apgar scores, can be safely -
News ArticleCovid has brought many hidden tragedies: elderly residents in care homes bereft of family visits, families in quarantine missing loved one’s funerals, and mums forced to go through labour alone. Much of this has been necessary, however painful, but Jeremy Hunt fears we’re getting the balance badly wrong in maternity care. That’s why he is backing The Mail on Sunday’s campaign to end lone births, which has been championed in Parliament by Alicia Kearns. Infection control in hospitals is critically important, but mothers’ mental health can’t be pushed down the priority list. Ima
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