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Found 22 results
  1. Content Article
    This report will set-out our family engagement process. It will also summarise the feedback received to date from the families who have been involved in HSIB investigations. The purpose is to for HSIB to share their family engagement process with other healthcare organisations involved in patient safety investigations and raise awareness of the value of an effective family engagement process in such investigations. The report will: Describe HSIB’s approach to family engagement in our investigations and what has informed our practice. Describe what has worked well in our approach to family engagement. Summarise what families and staff tell us about our approach. Explain what we have learned and plans for future work.
  2. News Article
    A campaign to reduce stillbirths, brain injury, and avoidable deaths in babies has failed to have any effect in the past three years, findings from the Royal College of Obstetricians and Gynaecologists show. The president of the college, Edward Morris, has urged maternity units across the UK to learn from the latest report and act on its recommendations. “We owe it to each and every person affected to find out why these deaths and harms occur in order to prevent future cases where possible,” he said. Read full story (paywalled) Source: BMJ, 19 March 2020
  3. Content Article
    Recommendations Human factors and behaviour: Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level. Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes. Workload and workforce challenges: Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population. This tool should complement the midwifery acuity tools currently implemented nationally. Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce. Communication: All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call. This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.
  4. News Article
    As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover. NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information. Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances. It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones. Tushar Srivastava, Founder and CEO of Nurturey, said: “Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.” Read full story Source: National Health Executive, 5 February 2020
  5. News Article
    Lives may be at risk unless the NHS reviews how stand-in doctors are recruited, a coroner has warned. Harry Richford's death after a series of failings at a hospital in Margate, Kent, was ruled "wholly avoidable". An inquest heard he was delivered by an "inexperienced" locum doctor who was new to the hospital. A national review into the recruitment, assessment and supervision of locums should be carried out, Christopher Sutton-Mattocks said in a report. The coroner wrote that particular emphasis should be considered upon the scope of locums' activities before they are left responsible for out-of-hours labour care. He issued 19 recommendations to prevent future deaths, including a request that NHS England and the Royal College of Obstetricians and Gynaecologists consider such a review, warning "there may be a risk to other lives both at this trust and at other trusts in the future". Read full story Source: BBC News, 19 February 2020
  6. News Article
    The government has announced an independent review into maternity services at an NHS trust where a number of babies have died. “Immediate actions” have also been promised and an independent clinical team has been placed “at the heart” of East Kent Hospitals University NHS Foundation Trust. It comes amid reports that at least seven preventable baby deaths may have occurred at the trust since 2016, including that of Harry Richford. Harry died seven days after his emergency delivery in a “wholly avoidable” tragedy, contributed to by neglect, in November 2017, an inquest found. Speaking in the House of Commons, the health minister Nadine Dorries confirmed the independent review would be carried out by Dr Bill Kirkup, who led the investigation into serious maternity failings at Morecambe Bay. It will look at preventable and avoidable deaths of newborns to ensure the trust learns lessons from each case and will put in place appropriate processes to safeguard families. The review is expected to begin shortly and work in partnership with affected families. Read full story Source: 13 February 2020
  7. News Article
    The boss of an NHS trust at the centre of concerns about preventable baby deaths has claimed the scale of the failings is not clearly defined. Susan Acott, Chief Executive of East Kent Hospitals Trust, said there had only been "six or seven" avoidable deaths at the trust since 2011. However, the BBC revealed on Monday that the trust previously accepted responsibility for at least 10. Ms Acott said some of the baby deaths were "not as clear-cut". A series of failings came to light during the inquest of Harry Richford who died seven days after his birth at the Queen Elizabeth the Queen Mother Hospital in Margate in November 2017. A coroner ruled Harry's death was "wholly avoidable" and was contributed to by hospital neglect. Ms Acott added she had not read a key report from 2015 drawing attention to maternity problems at the trust until December 2019. Ms Acott claims that from 2011 to 2020 there were "about six or seven" baby deaths that were viewed as preventable. She says the other deaths were being investigated adding "these things aren't always black and white". Read full story Source: BBC News, 12 February 2020
  8. News Article
    An NHS trust has been criticised for advising pregnant women to stay at home for as long as possible during labour to increase the chances of a “normal birth”. University Hospitals Bristol NHS Trust also suggested mothers should avoid having epidurals or inductions and should try to have a home birth. The advice has been described as “shocking” by experts, who said the guidance was contrary to evidence and could be “dangerous” for mothers and babies. Others criticised the language used by the trust which suggested women who needed medical help were somehow “abnormal”. Earlier this month, the Bristol trust paid out £5.8m in compensation to the family of a six-year-old boy after he was left brain damaged at birth following complications during labour. After being contacted by The Independent, the trust deleted the childbirth advice from its website and accepted it was “outdated”. Read full story Source: The Independent, 13 February 2020
  9. News Article
    A BBC News investigation has uncovered more preventable baby deaths at an NHS trust that has already been criticised for its maternity services. Four families said their babies would have survived had East Kent Hospitals NHS Trust provided better care. The NHS's Healthcare Safety Branch is investigating 25 maternity cases at the hospitals in Margate and Ashford. The trust has apologised for the care provided in two of the cases and said they were investigating a third. It has denied any wrongdoing in the fourth case. The government is due to receive the Healthcare Safety Branch's report into the 25 cases later, as well as a Care Quality Commission report from an inspection carried out in January. Last month, the BBC discovered at least seven preventable deaths may have occurred at the trust since 2016. Four further families have now spoken out, saying their babies would not have died if medics had provided better care. In two of the cases, the mothers said the actions of the trust left them feeling they were to blame for their babies' deaths. In a statement, East Kent Hospitals Trust it had set up a board sub-committee "to ensure we are complying with national safety standards and ensure we are implementing the coroner's recommendations fully and swiftly". "We are deeply saddened by the stories of families who have suffered the death of a much-loved baby, and we are extremely sorry for their loss," it added. Read full story Source: BBC News, 10 February 2020
  10. Content Article
    The 2015 Montgomery ruling created practical implications for how clinicians obtain consent and support patients to make decisions about their healthcare. The implication of the Montgomery ruling is that healthcare professionals must: clearly outline the recommended management strategies and procedures to their patient, including the risks and implications of potential treatment options discuss any alternative treatments discuss the consequences of not performing any treatment or intervention ensure patients have access to high-quality information to aid their decision-making give patients adequate time to reflect before making a decision check patients have fully understood their options and the implications document the above process in the patient’s record.
  11. Content Article
    This guideline written by Mid and South Essex Hospitals is designed to help maternity staff to identify, counsel and put the women who need antenatal and postpartum thromboprophylaxis on the correct pathway of care.
  12. News Article
    The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020
  13. News Article
    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 able to make an informed choice, knowing their choice would be fully respected. “Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said. “It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.” One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable." Read full story Source: The Telegraph, 26 January 2020
  14. News Article
    Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families. As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes. Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action. Read full story Source: The Independent, 26 January 2020
  15. News Article
    England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020
  16. News Article
    At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found. Significant concerns have been raised about maternity services at the trust. East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care". The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems. In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines. It highlights consultants who: failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested rarely attended CTG training were reported "as doing their own thing rather than follow guidelines". Read full story Source: BBC News, 23 January 2020
  17. Content Article
    Ah – a new year. A new decade. People around the world celebrate such affairs with fireworks, noisemakers, champagne and resolutions they’ll never keep. In America, we revel with all those things and ... the ’Granddaddy of them all‘... The Rose Bowl. The Rose Bowl is an annual college football face-off between two champion teams held in Pasadena, California. The event is huge, complicated, prestigious and widely anticipated. This musing on Rose Bowl activities and how they might highlight safety concepts ‘kicks off’ my 2020 Letter from America series. A renowned part of the franchise is the Tournament of the Roses parade. The 2020 parade theme was the ’Power of Hope‘. Volunteers, sponsors and organisations collaborate to produce a 5.5 mile spectacle involving over 40 floats, numerous marching bands and millions of flowers for viewer enjoyment. Collaboration is key to achieve medication safety too. In a recent study published in the Quality Management in Healthcare journal, a community health organisation’s successful method of frontline staff committee engagement generated process changes that culminated in reduced medication errors and increased near misses. Continuous quality improvement initiatives supported by these committees included technical handling and administration of medication, medication reconciliation, and enhancements to standardised treatment protocols. Following the pomp and beauty of the parade comes the gridiron... the grit... the sweat... the teamwork. College teams are selected based on their performance during the year. Their individual and team competencies are what get them to Pasadena and give their fans hope for a win. Competencies are important for developing reliability no matter what field you play on. The Society to Improve Diagnosis in Medicine (SIDM) has identified key competencies that should be considered for inclusion in health professions education programmes to improve the quality and safety of diagnosis in clinical practice. They fill a noticeable gap in health professional education by embedding reasoning and partnering skill development into healthcare curricula. The SIDM approach emphasises individual, team and system level skills to hone clinician diagnostic abilities and orientation to diagnosis as a team. In football and in healthcare, teams follow processes and plans but should be empowered to adapt when the situation calls for it. For example, TeamStepps is a US-government developed team training programme originally designed to enhance communication in acute care. A recent pilot study tested its application in mental health teams in schools to reduce staff burnout and turnover. This unique health environment adapted the TeamStepps method to improve organisational culture and provide support for the wide array of practitioners that provide care in schools. The success of the initiative improved team-based care delivery at the organisation. Football holds for the teams, management and consumers the potential not only for spectacular performance but for mistakes that can result in injury. Fatigue and distractions can often be a factor in football injury on the pitch; so too can these factors result in injury in healthcare. The Pennsylvania Patient Safety Authority (PSA) released a 4-year analysis of newborn falls in the hospital following birth. Parental fatigue was a primary contributory factor that emerged from the investigation. The PSA describes educational tactics to help parents understand the potential risks for infant drops and encourages them to ask for nursing assistance in feeding if they feel overly tired to keep their babies safe. Keeping track of disruptive behaviour is a relatively new effort for healthcare. Until recently, there was no way to raise a flag to indicate poor behaviour that can distract from team cohesion, coordination and communication. In a recent study, a large US health system devised a tool to evaluate disruptive behaviour among its ranks, measure its effect on teamwork, burnout and patient safety, and use that data to define improvement targets. In the sample, researchers found disruptive behaviour to exist in approximately 98% of work settings. The upside of this discouraging figure is that the tool effectively tracked disruptive behaviours so they can be addressed. There is hope for improvement – once a problem can be measured work can commence to fix it. While not a strategy, hope motivates, as presented by Sidney Dekker in his movie: Safety Differently. Hope situates the future in possibility, instils learning from what goes array and sustains efforts to stay true to goals. Let’s keep hope alive as we work to score touchdowns for safety in 2020.
  18. Content Article
    Recommendations include: assess patients for venous thromboembolism (VTE) risk with an easy to use automated scoring system provide the recommended prophylaxis regimen, depending on whether the mother is antepartum or postpartum reassesses the patient every 24 hours or upon the occurrence of a significant event, like surgery ensure that the mother is provided with appropriate VTE prevention education upon hospital discharge.
  19. Content Article
    Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each baby counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned. From 2015, they began collecting and analysing data from all UK units to identify lessons learned to improve future care. They will then be able to make recommendations on how to improve practice at a national level. This page brings together all of the information and resources about the Each baby counts programme.
  20. Content Article
    Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help.
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