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Found 500 results
  1. News Article
    Two-thirds of specialist mental health services for mothers planned funding cuts last year despite soaring demand. An analysis of NHS spending by the Royal College of Psychiatrists (RCP) found 27 out of 42 areas in England planned cuts totalling £3.2 million in the 2024/25 financial year. Some areas such as Norfolk and Waveney planned to slash their budget by £257,466 - almost 5%. It comes as NHS figures show a surge in demand for people seeking help, with 63,858 women accessing perinatal mental health services in the year to February 2025, compared to 43,053 women in the year to February 2022. Baroness Luciana Berger, chair of the Maternal Mental Health Alliance, told The Independent it was "deeply alarmed" by the findings. "Our research shows that investing in perinatal mental health services is not only a compassionate choice but an economically sound one. Unaddressed perinatal mental illness takes a significant toll on families and costs the UK economy £8.1 billion a year. "Cuts to these vital services risk devastating human consequences. Mental health remains the leading cause of maternal death. These tragedies will persist without continued investment and protection for specialist services.” Read full story Source: The Independent, 8 May 2025 Further reading on the hub: Mums with babies in NICU: postnatal maternal mental health support Healthy beginnings, hopeful futures: Black maternal mental health
  2. News Article
    A leading midwife and chair of government maternity inquiries has cited “significant concern about safety and wellbeing” following a substantial cut to nationally ring-fenced funding. The concerns follow more than £90m of service development funding being cut from maternity allocations and transferred into core integrated care board budgets in 2025-26, as revealed by HSJ this week. NHS England said “maternity care remains a top priority” and it was “misleading” to suggest otherwise. But leading maternity safety campaigners and royal colleges expressed concerns that funding will now be lost because of deficits and competing demands. NHSE 2025-26 planning guidance says organisations must still “improve safety in maternity and neonatal services, delivering the key actions of the ‘three-year delivery plan’”, as well as “paying particular attention to challenged and fragile services, including maternity and neonatal”. Donna Ockenden, a former senior midwife, who chaired a government-commissioned review into maternity failings in Shropshire and is currently leading its inquiry into Nottingham Hospitals, said on social media site X: “Talking to colleagues across perinatal services, the sense of disappointment is profound, with everyone I’ve spoken to tonight expressing significant concern about safety and the wellbeing of children and mental health.” Influential safety campaigner James Titcombe said the move was “pulling in the opposite direction to promises health and social care secretary Wes Streeting had made to families failed by poor maternity care”. Read full story (paywalled) Source: HSJ, 1 May 2025
  3. News Article
    Maternity, prevention, mental health, and children’s services are the national budgets seeing the biggest cuts after government and NHS England decided to slash ringfenced allocations, HSJ analysis reveals. The move has seen national “services development funding” (SDF) – money earmarked for national initiatives – slashed from £4.3bn in 2024-25 to just £500m (so far confirmed) for 2025-26. This year’s SDF is expected to grow as more funding is decided in coming months, but to nowhere near the levels seen in recent years. Mental health has lost £1bn of ringfenced funding, although ICBs are still expected to increase spend in line with total spending growth under the mental health investment standard. Lost SDF bundles in mental health include £215m for children and young people (including eating disorders), £275m for mental health support teams in schools, and £540m split between adult community and adult crisis services – all of which have been moved to ICB allocations. Maternity services received £95m overall in 2024-25 – which is reduced to just £2m this year, with three separate pots cut. Notably, this includes £22m for “Ockenden II workforce”. Funding following Donna Ockenden’s report into maternity failings at Shrewsbury and Telford Hospital Trust was largely earmarked for workforce expansions, and safety improvement work. Read full story (paywalled) Source: HSJ, 29 April 2025
  4. Content Article
    This Independent Report led by Professor Mary Renfrew was commissioned in May 2023 by the Department of Health (DoH) Northern Ireland (NI). It forms part of a broad programme of work to receive assurance on the safety of maternity and neonatal services for the population of NI. It resulted from two related developments: A request from the Coroner for Northern Ireland that the Department of Health NI take action to investigate her concerns following an inquest into the death of a baby that raised questions about care in Freestanding midwifery led units (MLUs). In the inquest report the Coroner identified a number of practice and system failings and shortcomings including the management of shoulder dystocia, fetal macrosomia (the baby being large for gestational age), and raised maternal body mass index (BMI). At the time of the inquest, all Freestanding MLUs in NI were closed. The Coroner found that a comprehensive review of the number of staff, experience, training, and policies should be conducted by the DoH, in the event of these Units reopening in the future. In response to this request, the Permanent Secretary asked the Chief Nursing Officer (CNO) for NI, along with the Midwifery Officer, to instigate an inquiry into the issues highlighted by the Coroner. Several other reports, both local and national, concerning the safety of services for pregnant women, new mothers, and babies required consideration of the wider health service context that influences midwifery and maternity care and services. In summary, the report advocates for the following changes: A shared strategic vision for safe, quality midwifery and wider maternal and newborn services in Northern Ireland with a regional framework for action. A reconfigured relationship with women, families and communities, ensuring respectful personalised care for all and a genuine voice in shaping services. A consistent, region-wide, evidence-informed approach to planning, funding, standards, provision, monitoring, and review of maternity and neonatal services. Improving clinical, psychological, and cultural safety and equity for women, babies and families across the whole continuum of care and in all settings. Changing the prevailing work culture to implement an enabling environment for all staff and managers, including ensuring midwives are represented at senior management levels, tackling silo working, and developing an open learning culture at every level of the system. Supporting midwives to provide quality midwifery care and services across the whole continuum of maternal and newborn care, with investment in community as well as hospital services, and increasing midwives’ influence over the safety and quality of care and services. Better oversight through improved accountability, monitoring, evaluation, and research. A unified approach to education and training of all staff, including leadership development - especially for midwives - and capacity building for the future.
  5. Content Article
    Thyroid disease is a common endocrine disorder in women of childbearing age. There is variation in clinical practice and approach to thyroid diseases globally, in part influenced by differences in population iodine status. There remains controversy regarding testing for and management of thyroid disorders before conception, during pregnancy and postpartum. This guideline presents the available evidence for best practice and where evidence is lacking, consensus opinion by a multidisciplinary, cross-specialty team of authors is presented. Both inadequate and excessive treatment of thyroid disorders, the choice of treatment, as well as delayed commencement and adjustment of treatment, can result in detrimental effects on the pregnancy and fetus. Therefore, care should be optimised when planning pregnancy, during pregnancy and after birth, and where possible, provided by clinicians with appropriate obstetric and endocrine experience.
  6. Content Article
    Race and ethnic inequalities in health are widely recognised, with much work needed to improve care, diagnosis and treatment, and outcomes for patients. Racism is also evident within healthcare organisations and the impact on staff can be devastating.  In this blog, we’ve collated a wide range of resources, including the latest research, the barriers patients face, improvement initiatives, health inequalities in maternity, and staff discrimination to evidence some of the key patient safety issues and the need for greater investment in this area. Barriers to diagnosis and treatment 1 Perceived barriers to accessing mental health services among black and minority ethnic communities: a qualitative study In most developed countries, substantial disparities exist in access to mental health services for black and minority ethnic populations. This study sought to determine perceived barriers to accessing mental health services among people from these backgrounds to inform the development of effective and culturally acceptable services to improve equity in healthcare. 2 ‘Mistreatment’ due to the colour of your skin A blog highlighting the barriers in healthcare faced by patients due to the colour of their skin. Impacting factors can include explicit racial bias, which includes discrimination and prejudice; implicit racial bias; missing data; lack of trust; and reduced access. These can lead to misdiagnoses and delays in treatment, which can ultimately cause harm and preventable death. 3 95% of healthcare professionals do not feel confident diagnosing dermatology conditions across skin tones This blog by Pastest, a provider of medical exam preparation resources, explores how different organisations are developing transformative initiatives to diversify clinical practice. It highlights the results of a global survey that reveals a critical gap in dermatological diagnosis across skin tones and explores the need for a multifaceted approach to anti-racist medicine. 4 Equity in medical devices: independent review A core responsibility of the NHS is to maintain the highest standards of safety and effectiveness of medical devices available for all patients in its care. Evidence has emerged, however, about the potential for racial and ethnic bias in the design and use of some medical devices commonly used in the NHS, and that some ethnic groups may receive sub-optimal treatment as a result. In response to these concerns, the UK Government commissioned this independent review on equity in medical devices. In its final report, the Review sets out the need for immediate action to tackle the impact of ethnic biases in the use of medical devices. 5 Skin assessment in patients with dark skin tone This article in the American Journal of Nursing provides basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure the performance of effective skin assessments in all patients. 6 “We’re not taken seriously”: Describing the experiences of perceived discrimination in medical settings for Black women Cervical cancer disparities persist for Black women despite targeted efforts. Reasons for this vary; one potential factor affecting screening and prevention is perceived discrimination in medical settings. Inequalities in maternity 1 For black women in the UK, a fear of pregnancy is far from irrational In this blog for Refinery 29, journalist L'Oréal Blackett discusses the additional risk and associated worries faced by black pregnant women in the UK. With black women four times more likely to die in childbirth than white women, and 40% more likely to suffer a miscarriage, she examines what action the government is taking to improve outcomes for black women and their babies. She speaks to a number of campaigners who highlight the importance of including black women at every stage of research and policy to tackle race-based health inequalities. 2 Five X More campaign: Improving maternal mortality rates and health outcomes for black women In this interview, Patient Safety Learning talks to Tinuke, co-founder of the Five X More campaign and founder of the mothers group, Mums and Tea. Tinuke started the Five X More campaign as a response to the MBRRACE 2018 report which highlighted that black women in the UK are five times more likely to die in pregnancy and childbirth in comparison to a white woman. 3 Review of neonatal assessment and practice in Black, Asian and minority ethnic newborns: Exploring the Apgar score, the detection of cyanosis, and jaundice The results of a commissioned review undertaken by Sheffield Hallam University highlights a number of ‘reliability concerns’ around three current neonatal assessments and perinatal practices – the Apgar score and the detection of cyanosis and jaundice. It calls for immediate update of maternity guidelines that refer to assessments by skin colour and the increased use of screening tool devices, including oximeters and bilirubinometers. Urgent research is also needed which focuses on enhancing the reliability of these tools especially for darker skinned babies. 4 Addressing critical gaps in Black maternal mental healthcare: a new partnership project is launched Sandra Igwe is the Founder and CEO of The Motherhood Group. In this interview Sandra tells us about a new partnership project, bringing together The Motherhood Group, Centre for Mental Health, and the Maternal Mental Health Alliance to address critical gaps in Black maternal mental healthcare. Staff discrimination 1 NHS Confederation - Shattered hopes: black and minority ethnic leaders’ experiences of breaking the glass ceiling in the NHS This report by NHS Confederation looks at the lived experience of senior black and minority ethnic leaders in the NHS. The report highlights that more than half of those surveyed considered leaving the health service in the last three years because of their experience of racist treatment while performing their role as an NHS leader. Colleagues, leaders and managers seemed to be a particular source of racist treatment, more so than members of the public. This suggests that more focused efforts are required at every level to reduce the incidence of racist behaviour and to improve awareness among all staff of the impact of this type of discrimination. 2 Resource for nursing and midwifery professionals to combat racial discrimination against minority ethnic nurses, midwives and nursing associates Racism is unacceptable and it has no place in health and care. But we know that it exists and that the impact on staff can be devastating. All registered professionals have responsibility under the Nursing and Midwifery Council (NMC) Code to challenge discriminatory behaviour, creating an environment where people are treated as individuals and with dignity and respect. This resource is designed to support nurses, midwives and nursing associates, providing advice on the action you can take if you witness or experience racism. It also supports those in leadership roles to be inclusive leaders. 3 Too hot to handle? Why concerns about racism are not heard... or acted on This report aims to understand the NHS response to racism, what trusts and healthcare organisations do about it and how effective they are at addressing it. It brings together key learning from a number of significant tribunal cases and responses from 1,327 people to a survey about their experiences of raising allegations of racism within their organisations. 4 Closing the gap: A guide to addressing racial discrimination in disciplinaries A guide from NHS Providers to help health service trusts tackle racial discrimination in disciplinary procedures and promote inclusivity. 5 Nursing narratives: Racism and the pandemic This report describes the findings of a study that collected stories of the working lives of Black and Brown healthcare staff during the Covid-19 pandemic. The study asked them to reflect on their experiences and highlight the changes they would like to see. It highlights a number of issues around victimisation, access to PPE, speaking up and risk assessments. 6 Racism which impacts healthcare staff endangers patient care As well as a moral issue, tackling racism affecting NHS staff is a crucial part of improving patient safety and care, says MDX Research Fellow Roger Kline. In this blog, Roger looks at the risks of racism on patient safety. Improvement initiatives 1 How Lambeth is closing the health inequality gap for Black and minority ethnic patients with high blood pressure Black and minority ethnic patients with high blood pressure have benefited from a project which was run by two Lambeth GP practices. The project aimed to reduce the very significant difference in blood pressure control (hypertension) between Black and minority ethnic patients and white patients. The year-long project resulted in the two practices achieving some of the best outcomes ever seen in South East London for overall hypertension control, with a 12% inequality gap for blood pressure control between black and white patients completely eradicated. In addition, over 300 patients from the local community were newly diagnosed with hypertension. 2 Patient and Carer Race Equality Framework - community This video provides an introduction to Sheffield Health and Social Care NHS Foundation Trust's (SHSCFT's) Patient and Carer Race Equality Framework (PCREF). The PCREF aims to help the Trust's staff and communities understand how to have sensitive conversations with patients and carers and to get better information from them. This will mean the Trust is more culturally aware and able to offer culturally appropriate care by understanding the barriers ethnic minority communities face in getting healthcare services for diagnosis and treatment. 4 Excellence through equality: Anti-racism as a quality improvement tool This report from the BME Leadership Network comprises examples of anti-racist initiatives from BME Leadership Network members, to help advance equality within the workforce and for service users. 5 Be the Change: How to tackle racial inequalities in health and care charities A few years ago, National Voices created an inclusion action plan to try to narrow the gaps in racial inequalities by driving improvements in their recruitment practices, organisational culture, influencing activities and work with people with lived experience. A key part of that plan was convening their members to learn from each other, so they organised a series of four members-only roundtables for focused, pragmatic and open discussion. This report, highlights the main learnings in each of the areas, and draws out general advice from all these conversations. They hope it will give colleagues in the health and voluntary sectors ideas for what they could do, alongside practical tools to take action. 6 Mind the Gap: A handbook of clinical signs in Black and Brown skin Mind the Gap is a Handbook to raise awareness of how symptoms and signs can present differently on darker skin as well as highlighting the different language that needs to be used in descriptors. The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. 7 The Health Foundation: Bringing an anti-racism approach to quality improvement in maternity care Black Maternity Matters is a collaboration supporting perinatal staff to reduce the inequitable maternity outcomes faced by Black mothers and their babies. Through a ground-breaking programme of training, including anti-racist education, peer support, and quality improvement, it supports maternity systems to provide safer, equitable care. In a recent episode of the Leading Improvement in Health and Care podcast, Penny Pereira, Q Managing Director, spoke to three improvement leaders from the Black Maternity Matters programme. Structural racism 1 Institute of Health Equity: Structural racism, ethnicity and health inequalities in London Racism in London is widespread and persistent causing damage to individuals, communities and society as a whole. Its impacts are experienced in different ways and to varying levels of intensity related to individual experiences, socioeconomic position and other dimensions of exclusion such as disability, age and gender. The intersections with other dimensions of exclusion can amplify the effects of racism. The focus of this review is on the effects of racism on health and its contribution to avoidable inequalities in health between ethnic groups – a particularly unacceptable form of health inequity. It is urgent that society tackle the damage to health and wellbeing as a result of racism. 2 Structural racism as a contributor to lung cancer incidence and mortality rates among Black populations in the United States Although racial disparities in lung cancer incidence and mortality have diminished in recent years, lung cancer remains the second most diagnosed cancer among US Black populations. Many factors contributing to disparities in lung cancer are rooted in structural racism. To quantify this relationship, Robinson-Oghogho et al. examined associations between a multidimensional measure of county-level structural racism and county lung cancer incidence and mortality rates among Black populations, while accounting for county levels of environmental quality. 3 Interrogating and uprooting systemic racism in the emergency department Systemic racism refers to systems in which norms and practice patterns reinforce racial and ethnic inequalities even in the absence of individual intentions to do so. Uncovering subtle, overt and pervasive instances of racism that influence and change the trajectory of patient care is important. Emergency departments (EDs) offer a distinct environment where equity is not just a concept, but a fundamental practice that should be woven through all interactions between the patient, healthcare professionals and the system. For this reason, EDs are poised to lead health equity advocacy in the delivery of high-quality care. This JAMA Health Forum viewpoint article looks at evidence relating to ED systems’ vulnerability to systemic racism and maps a path forward to dismantle racism in the ED. 4 Women from ethnic minorities face endemic structural racism when seeking and accessing healthcare Women from ethnic minorities are voicing their concerns that they face endemic structural racism when seeking and accessing healthcare, and they feel that their symptoms and signs are more often dismissed. It is vital that patients are listened to when they say that they feel this is also due to structural racism in healthcare. 5 Structural racism — A 60-year-old Black woman with breast cancer This study uses the case study of a 60-year-old Black woman with breast cancer as an example of structural racism and propose three critical strategies for addressing structural racism in health care. These strategies hinge on shifting the focus of work on racial differences in health outcomes from biologic or behavioural problems to the design of health care organisations and other social institutions. Research 1 Language-based exclusion associations with racial and ethnic disparities in thyroid cancer clinical trials Racial and ethnic disparities in thyroid cancer care may be reduced by improving enrolment of more diverse patient populations in clinical trials. This study in the journal Surgery looked at trial eligibility criteria and enrolment to assess barriers to equitable representation. 2 Differences in care team response to patient portal messages by patient race and ethnicity The use of patient portals to send messages to healthcare teams is increasing. This JAMA Network Open cross-sectional study of nearly 40,000 US patients aimed to find out whether there are differences in how care teams respond to messages from Asian, Black and Hispanic patients compared with similar White patients. The authors found that messages asking for medical advice sent by patients who belong to minoritised racial and ethnic groups were less likely to receive a response from doctors and more likely to receive a response from registered nurses. This suggests these patients receive lower prioritisation during triaging. The differences observed were similar among Asian, Black and Hispanic patients. 3 Racial implicit bias and communication among physicians in a simulated environment This JAMA Network Open study aimed to explore whether standardised patients in a simulated environment can be effectively used to explore racial implicit bias and communication skills among doctors. For this cross-sectional study, 60 doctors were placed in an environment calibrated with cognitive stressors common to clinical environments. The results reflected expected communication patterns based on prior research (performed in actual clinical environments) on racial implicit bias and physician communication. The authors believe that this simulation and the process of its development can inform interventions that provide opportunities for skills development and assessment of skills in addressing racial implicit bias. 5 Racial differences in shared decision-making about critical illness This US study looked at how critical care doctors approach shared decision-making with Black compared with White caregivers of critically ill patients. The authors found that racial disparities exist in critical care clinicians' approaches to shared decision-making and suggest potential areas for future interventions aimed at promoting equity. 6 Impact of healthcare algorithms on racial and ethnic disparities in health and healthcare This systematic review conducted for the Agency for Healthcare Research and Quality (AHRQ) aimed to examine the evidence on whether and how healthcare algorithms exacerbate, perpetuate or reduce racial and ethnic disparities in access to healthcare, quality of care and health outcomes. The results showed that algorithms potentially perpetuate, exacerbate and sometimes reduce racial and ethnic disparities. Disparities were reduced when race and ethnicity were incorporated into an algorithm to intentionally tackle known racial and ethnic disparities in resource allocation (for example, kidney transplant allocation) or disparities in care (for example, prostate cancer screening that historically led to Black men receiving more low-yield biopsies). 7 Characteristics of publicly available skin cancer image datasets: a systematic review Artificial intelligence (AI) is increasingly being used in medicine to help with the diagnosis of diseases such as skin cancer. To be able to assist with this, AI needs to be ‘trained’ by looking at data and images from a large number of patients where the diagnosis has already been established, so an AI programme depends heavily upon the information it is trained on. This review, published in The Lancet Digital Health, looked at all freely accessible sets of data on skin lesions around the world. These are just a selection of the resources we have on the hub, read more in the health inequalities section of the hub. Share your insights We'd like to hear from patients about your experiences and how it has impacted your care. Or perhaps you are clinician or researcher with a perspective to share on health inequalities? Please leave a comments below (sign up here first for free), or contact us directly at [email protected].
  7. News Article
    A woman dies every two minutes due to failures in maternal healthcare, according to shocking global data that has prompted stark warnings about the impact of cuts to aid funding by the US and the UK. A new report from the World Health Organisation (WHO) has revealed that there were 260,000 maternal deaths in 2023, equating to 712 women a day or 30 per hour – with the vast majority in sub-Saharan Africa. The WHO has warned that the global target for all UN member states to reduce maternal deaths – down to 71 per 100,000 by 2030 – will be missed by more than twice this amount as “the pace of progress has slowed to a near standstill”. Leading health organisations including the WHO have warned that recent sweeping cuts to international aid by the US government, which amount to more than £595m ($770m) for maternal health and family planning, will risk “a shift backwards” in the progress made on cutting maternal deaths – defined as any death related to or aggravated by pregnancy, or within six weeks of the end of a pregnancy. Speaking at a press conference, Dr Bruce Aylward, assistant director general of universal health coverage for the WHO, said: “The funding cuts risk not only that progress, but we could have a shift backwards.” He said that cuts were already “affecting access to lifesaving supplies and medicines, and especially treatments for some of the leading causes of maternal death”. Read full story Source: The Independent, 10 April 2025
  8. News Article
    Postnatal mental health services are closing across the country due to a lack of funding despite record numbers of women seeking help, The Independent can reveal. One in five of the 600,000 women a year who give birth in the UK experience a mental health condition, NHS figures show – and a quarter have a negative birth experience. Mental health conditions are the leading cause of maternal death between six weeks and a year after birth – accounting for one in three deaths, according to the Oxford University-led group MBBRACE-UK, which records all maternal and baby deaths in the UK. Postnatal suicide rates rose by more than 50 per cent during the pandemic and have remained high ever since. Between 2017 and 2019, the rate of suicide was 0.46 for every 100,000 mothers who gave birth in that period, but between 2021 and 2023 - the latest figures available - the rate was 0.70 per 100,000 mothers. But in January, the Government announced it was scrapping funding for the nationwide rollout of Women’s Health Hubs, which aimed to improve access to services such as perinatal mental health support. “This is a completely neglected mental health crisis, on an extremely large scale,” Danny Chambers MP, the Lib Dem spokesperson on mental health, warned Parliament in February. "And now several charities which plug the gaps in NHS support, by helping parents unable to access NHS help or who are stuck on waiting lists, have been forced to close or suspend services because of funding cuts." Read full story Source: The Independent, 8 April 2025
  9. Content Article
    Catch up on previous Maternity & Newborn Safety Investigations (MNSI) webinars and view slides from the presentations. Webinars and slide topics: Think beyond sepsis Sudden Unexplained Death in Epilepsy (SUDEP) First trimester deaths in England from venous thromboembolism associated with hyperemesis Maternal death from pulmonary embolism
  10. Content Article
    The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. Their webinar series Exploring learnings from MNSI safety investigations is now available on their website and includes the following topics: Think beyond sepsis Sudden Unexplained Death in Epilepsy (SUDEP) First trimester deaths in England from venous thromboembolism associated with hyperemesis Deaths in England in the first trimester of pregnancy: national patterns and safety recommendations Maternal death from pulmonary embolism.
  11. Content Article
    What does a mother need to know to ensure that she has a safe pregnancy and delivery? What are some warning signs to watch for? And what are a woman’s rights while going through a pregnancy and delivery? Join maternal health expert Dr Femi Oladapo on Science in 5. This episode is published as part of the campaign in 2025 for World Health Day dedicated to Maternal and Newborn Health. Further reading on the hub: Healthy beginnings, hopeful futures: Black maternal mental health Top picks: Key resources for maternity safety
  12. Content Article
    Women today are more likely than ever to survive pregnancy and childbirth according to a major new report released today, but United Nations (UN) agencies highlight the threat of major backsliding as unprecedented aid cuts take effect around the world. Released on World Health Day, the UN report, Trends in maternal mortality, shows a 40% global decline in maternal deaths between 2000 and 2023 – largely due to improved access to essential health services. Still, the report reveals that the pace of improvement has slowed significantly since 2016, and that an estimated 260 000 women died in 2023 as a result of complications from pregnancy or childbirth – roughly equivalent to one maternal death every two minutes. The report comes as humanitarian funding cuts are having severe impacts on essential health care in many parts of the world, forcing countries to roll back vital services for maternal, newborn and child health. These cuts have led to facility closures and loss of health workers, while also disrupting supply chains for lifesaving supplies and medicines such as treatments for haemorrhage, pre-eclampsia and malaria – all leading causes of maternal deaths. Without urgent action, the agencies warn that pregnant women in multiple countries will face severe repercussions – particularly those in humanitarian settings where maternal deaths are already alarmingly high.
  13. Content Article
    World Health Day, celebrated on 7 April, kicks off a year-long campaign on maternal and newborn health. This year's campaign, titled ‘Healthy beginnings, hopeful futures’, will urge governments and the health community to ramp up efforts to end preventable maternal and newborn deaths, and to prioritise women’s longer-term health and well-being. It is led by The World Health Organization.  The Motherhood Group focuses on creating supportive spaces where Black mothers can find community, resources, and advocacy. In this interview Sandra Igwe, Founder and CEO of the Motherhood Group, reflects on this year’s theme and the continuation of disparities in Black maternal mental health. Sandra highlights key areas for action and explains how a greater focus on lived experience leads to better outcomes for women and babies.  What does a ‘healthy beginning and hopeful future’ look like for Black maternal mental health? A healthy beginning means Black mothers receiving respectful, dignified care where their voices are heard and their concerns taken seriously. It means having access to culturally competent mental health support without stigma. Drawing from our "Interconnecting Themes" framework, a hopeful future includes: Community and Connection: Strong support networks both online and in-person Advocacy and Voice: Black mothers empowered to speak for themselves and be heard Education and Knowledge: Better information for both mothers and healthcare providers Healthcare Transformation: Systems that acknowledge cultural differences and provide equitable care Safe Spaces: Environments where Black mothers can be vulnerable without judgment This vision requires reframing Black maternal health as a human rights imperative and addressing it through an anti-racist approach, as highlighted by speakers at our conference. What are the big issues that need addressing? The most pressing issues include systemic racial disparities in maternal healthcare, lack of cultural competency among healthcare providers, insufficient mental health support for Black mothers, and the dismissal of Black women's pain and concerns. Our training workshops highlight specific challenges including: Mental health stigma within Black communities Barriers to effective engagement with healthcare services Language and cultural barriers affecting quality of care The "Strong Black Woman" myth that prevents many from seeking help Black mothers being less likely to be identified with perinatal depression due to inadequate screening tools The difficulty many Black mothers face expressing emotional distress in a system that applies western/eurocentric labels These issues disproportionately affect Black women, who in the UK are four times more likely to die during childbirth than white women and consistently report poorer experiences throughout their maternity journey. What results have you seen for women and their babies when they receive good mental health support? When Black mothers receive appropriate mental health support, we see transformative outcomes: stronger maternal-child bonding, better parenting confidence, improved family dynamics, and children who thrive emotionally and developmentally. Mothers report feeling more empowered to navigate healthcare systems and build supportive networks. Our initiatives like the NICU, Early Life and Loss panel discussions reveal how proper support can help mothers through the most challenging circumstances. The community-led initiatives showcased at our conference demonstrate that when Black mothers are supported appropriately, they often become powerful advocates and create solutions for others facing similar challenges. What more needs to happen by who? We need coordinated action across multiple fronts: Policy: Implementation of culturally sensitive care standards and mandatory training on racial bias for all healthcare workers. Funding: Greater investment in community-based maternal support services and grassroots solutions. Training: Healthcare professionals need comprehensive education on recognizing and addressing racial disparities and implicit bias. Healthcare Providers: Maternity services should collect and act on ethnicity data to identify and address disparities. GPs and Midwives: Need to create safe spaces where Black mothers feel heard and validated, with better screening for mental health concerns that considers cultural context. Community Organizations: Continued development of diverse focus groups, patient forums, and support groups (both digital and face-to-face). Our conference demonstrates the multi-stakeholder approach needed, bringing together NHS leadership, politicians like MP Florence Eshalomi and Rt Hon Diane Abbott MP, medical professionals, community groups, and most importantly, mothers with lived experiences. Final thoughts? The conversation around Black maternal health must move beyond statistics to recognize the lived experiences of Black mothers. As our conference theme "Building Better Futures: Community-Led Solutions" suggests, the most effective approaches center on the voices of those most affected. Initiatives like our project work with Genomics England and "Avoiding Brain Injury in Childbirth" (ABC) show that when Black mothers' perspectives are included in research and service design, the outcomes improve for everyone. This World Health Day theme aligns perfectly with our mission of creating healthy beginnings through community, connection, education, and advocacy. We believe that rest, as highlighted in our "Rest as Revolution" conference session, is also a critical component of maternal wellbeing that is often overlooked for Black mothers. True progress requires not just acknowledging disparities but actively dismantling the systems that create them and building new, more equitable approaches. Related hub content Addressing critical gaps in Black maternal mental healthcare: a new partnership project is launched (interview with Sandra Igwe) Working with bereaved parents for safer and more equitable care Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Women who experience high-risk pregnancies are too often forgotten when their babies are born Mums with babies in NICU: postnatal maternal mental health support Top picks: Key resources for maternity safety
  14. Content Article
    Ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. These services act as the frontline responders, providing immediate care and facilitating timely transport to appropriate healthcare facilities. World Patient Safety Day, observed annually on 17 September, serves as a global platform to raise awareness about patient safety and encourage collaborative efforts to reduce harm in healthcare settings. The theme for 2025, 'Safe care for every newborn and every child', underscores the critical importance of safeguarding our youngest and most vulnerable patients from preventable harm. In the UK, ambulance services play a pivotal role in ensuring the safety of mothers and their newborns during urgent and emergency situations. These services act as the frontline responders, providing immediate care and facilitating timely transport to appropriate healthcare facilities. Their contributions are multifaceted, encompassing emergency childbirth assistance, neonatal transfers and the management of obstetric emergencies. In addition, many women and families will use the 999/111 service throughout the childbearing continuum, often using these services as a gateway to accessing maternity care. A recent review of Maternity and Newborn Safety Investigations (MNSI) highlighted that 6 in 10 independent investigations that met the criteria for MNSI involved the ambulance service. Out-of-hospital births, though relatively rare, present unique challenges for ambulance clinicians. Intrapartum care accounts for approximately 0.05% of emergency medical services' caseload, with only about 10% of these cases resulting in deliveries managed by ambulance staff. This limited exposure can lead to a decline in obstetric clinical skills, potentially impacting patient care. To address this, continuous training and simulation exercises are essential. For instance, the London Ambulance Service has developed a bespoke communication tool to support midwives in out-of-hospital settings, ensuring effective communication during the transfer of women or babies in emergencies and delivers bespoke mandated emergency training to its frontline clinicians. Such initiatives enhance the preparedness of ambulance clinicians to manage emergency deliveries safely; however, these are not standardised across services. Challenges and areas for improvement Despite their critical role, UK ambulance services face challenges that can impact maternal and neonatal safety. Incidents of delayed response times have been reported, leading to tragic outcomes. For example, a three-day-old baby named Wyllow-Raine Swinburn passed away after an eight-minute delay in answering a 999 call and a 31-minute wait for the ambulance to arrive. Although the delays were not deemed the direct cause of death, they highlighted inefficiencies in the emergency response system. In other cases, the lack of effective training for ambulance clinicians impacted upon the management of a time critical breech delivery, with tragic consequences. Such cases underscore the need for systemic improvements, including better resource allocation, enhanced training and the implementation of robust protocols to minimise delays in emergency response. Collaboration between ambulance services and midwifery teams is essential for improving outcomes in maternal and neonatal emergencies. The development of communication tools and training programmes exemplifies efforts to standardise information exchange during emergencies, thereby reducing the potential for errors and delays. Furthermore, ambulance services are increasingly recognising the importance of specialised roles focused on maternity care. For instance, paramedics with additional training in neonatal and maternity care can provide more comprehensive support during emergencies. Susie, a paramedic with the Northwest Ambulance Service, highlighted her passion for improving maternity care within the ambulance service, emphasising the importance of continuous professional development in this area. Conclusion As we observe World Patient Safety Day 2025, it is imperative to acknowledge and support the vital role of UK ambulance services in safeguarding mothers and their newborns during and following pregnancy. Continuous training, effective communication tools and collaborative practices are essential to enhance the safety and quality of care provided. By addressing existing challenges and building on successful initiatives, we can move closer to the goal of ensuring safe care for every newborn and every child from the very start. Further reading Exploring the pre-hospital setting for the emergency care and transfer of neonates: the role of UK ambulance and neonatal transport services Displaced risk. Keeping mothers and babies safe: a UK ambulance service lens An exploration of maternity and newborn exposure, training and education among staff working within NWAS Disparities In Access to the Northwest Ambulance Service during pregnancy, birth and postpartum period and its association with neonatal and maternal outcomes World Patient Safety Day 2025
  15. Content Article
    The Thirlwall Inquiry was set up to examine events at the Countess of Chester Hospital following the trial and subsequent convictions of Lucy Letby for the murder and attempted murder of babies at that hospital. This report was commissioned by the Thirlwall Inquiry. It summarises key themes from responses to a questionnaire sent by the Inquiry to all other NHS trusts with maternity and neonatal units in England. With the evidence and submissions phase of the Inquiry now closed, the Nuffield Trust publish it here in the form submitted to the Inquiry as of April 2024. Overarching themes For almost all the areas covered in the questionnaire there were existing regulations, mechanisms or guidance in place in the NHS. Within neonatal services there were additional reporting routes and requirements to take into account over and above those which apply across the NHS as a whole. In a small number of areas (for example use of CCTV) we found limited guidance. The infrastructure within trusts affected the processes they have in place to manage safety and risks. For example, there was variation between trusts in the availability of electronic systems to support access to medical records, medicines management and storage facilities, the maturity of systems for data collection, reporting and triangulating information, and ease of access to the ward for parents. However, policies, structures and processes on their own are not sufficient to ensure services are safe and effective. A wide body of research indicates that culture and leadership are critical, and a positive culture is needed for systems and processes to achieve their aims. Where there is variation in how trusts manage issues, this will reflect a combination of the circumstances of the organisation and the leadership approach to addressing issues. Some organisational circumstances are unique, but there are many factors affecting the whole NHS, or neonatal care specifically, for example resource and workforce pressures. Culture and leadership at an organisational level are also impacted by national leadership and management of the NHS. In some cases the quantity of guidance, reporting requirements, number of external regulators, and the frequency with which these change, leads to a risk that responding to external scrutiny takes precedence over learning and action within the organisation.
  16. Content Article
    The UK has one of the lowest maternal mortality rates in the world, but black women are still twice as likely as white women to die from pregnancy related causes. Historically, this disparity has been as high as fivefold, kickstarting initiatives such as Five X More to push for improved maternal outcomes in black women. Despite improvements in recent years, racial inequalities stubbornly persist. In this BMJ feature, Samara Linton explores why—and what’s being done to improve outcomes. Related reading on the hub: Top picks: Race and ethnic health inequalities
  17. News Article
    A trust has moved the care of some sick babies out of one of its neonatal units at the Care Quality Commission’s request. Leeds Teaching Hospitals Trust said babies requiring more than 24 hours of neonatal intensive or high dependency care would now be moved from St James’ University Hospital to the Leeds General Infirmary, which has a neonatal intensive care unit, or alternative hospitals. The trust confirmed this followed a request from the Care Quality Commission, which carried out unannounced inspections of its maternity and neonatal services in December and January. Previously St James’ had been providing “less complex elements of intensive care and high dependency care”, despite only having a “special care baby unit” (SCBU), which typically provides care for less seriously ill babies than a NICU. This unusual position had been agreed with the Yorkshire and Humber neonatal operational delivery unit. The trust said its neonatal doctors and nurses worked across the units in both hospitals, and were qualified and trained to treat babies requiring the highest level of care. The trust’s maternity services have recently been criticised by a group of parents, and HSJ last week highlighted how they have been rated “red” for high perinatal mortality in the national maternity services audit four times in the past seven years. Chief nurse Rabina Tindale said: “Individuals are still able to give birth at St James’ Hospital and babies will receive the appropriate level of care in our SCBU, but this [change] does mean that if babies need more than 24 hours of intensive care or high dependency care, they must be transferred to Leeds General Infirmary or another unit.” Read full story (paywalled) Source: HSJ, 1 April 2025
  18. Content Article
    After another damning coroner’s report following the preventable death of a baby at a Lancashire hospital, this HSJ podcast take a closer look at why the NHS is beset with so many maternity scandals.
  19. News Article
    An NHS trust criticised over the avoidable death of a newborn baby was paid £2m for providing good maternity care, the BBC can reveal. A senior coroner ruled on Friday that University Hospitals of Morecambe Bay (UHMB) NHS trust contributed to Ida Lock's death and had failed to learn lessons from previous maternity failures. Despite this, the trust claimed it had met all 10 standards under an NHS scheme aimed at promoting safe treatment. Ida's mother Sarah Robinson said it was "another kick in the teeth" while her father Ryan Lock labelled it "disgusting". The trust, which has previously apologised for its failings in Ida's care, declined to comment about the NHS payment scheme. Senior coroner for Lancashire James Adeley concluded that Ida had died due to the gross failure of three midwives to provide basic medical care. Ida, who was born at the Royal Lancaster Infirmary (RLI) on 9 November 2019, died a week later after suffering a serious brain injury due to a lack of oxygen. Dr Adeley ruled her death had been caused by the midwives' failure to deliver the infant "urgently when it was apparent she was in distress" and contributed to by the lead midwife's "wholly incompetent failure to provide basic neonatal resuscitation". He said eight opportunities had been missed "to alter Ida's clinical course". Read full story Source: BBC News, 26 March 2025
  20. Content Article
    On 9 November 2019, a woman who was pregnant with Ida, attended the Royal Lancaster Infirmary Labour Ward in early labour. Ida was a normal child whose death was caused by a lack of oxygen during her delivery. This occurred due to the gross failure of the three midwives attending her to provide basic medical care to deliver Ida urgently when it was apparent she was in distress and contributed to by the lead midwife‘s wholly incompetent failure to provide basic neonatal resuscitation for Ida during the first 3 1/2 minutes of her life that further contributed to Ida’s brain damage. Ida died on 16 November 2019 at the Royal Preston Hospital neonatal intensive care unit. The inquest was one in which Article 2 was fully engaged as a result of the Trust’s clinical governance arrangements, inadequate investigations, a lack of transparency and openness, a failure to respond to a detailed complaint letter, a failure to comply with the Duty of Candour, disputing the findings of the Secretary of State for Health’s independent review panel (HSIB now MNSI), failing to notify external monitoring bodies and failing to comply with internal protocols. The Trust’s lack of compliance with clinical governance requirements in the investigation into Ida’s death had significant similarities with the criticisms made in 2015 of the Trust as set out in The Report of the Morecambe Bay Investigation, otherwise known as the Kirkup Report. [REDACTED] who gave evidence at the inquest, expressed the view that there was a deep seated and endemic culture of defensiveness in respect of maternity incidents at the Trust. [REDACTED] also said that the investigation showed elements of failing to identify significant care issues, brevity, defensiveness and was conducted by unskilled investigators. Matters of Concern A: Culture of Candour [Trust, ICB and DHSC] 1. I am concerned that there is not a culture of candour within University Hospitals of Morecambe Bay NHS Foundation Trust (Trust) and the impact that this has on safety, learning and implementing required changes to prevent deaths. Urgent action is required by the Trust to meaningfully embed the Dury of Candour. 2. [REDACTED]’s evidence to the inquest was that a deep-seated and endemic culture within the Trust leads to denial and a failure to learn. [REDACTED]’s Investigation report was published in 2015, the Trust is ten years on and still issues and themes identified in 2015 were very much in issue in 2019 and still exist at the Trust as identified by Ida’s inquest. 3. The Trust’s approach to the inquest has been one of a lack of transparency and openness, failure to provide relevant information and a failure to identify with candour the defective clinical governance processes that have operated at the Trust from 2019 to present day. 4. The Trust did not disclose that they had failed to notify the external bodies namely the CQC and the then CCG [ICB] via STEIS and the Trust’s internal Serious Incidents Reporting Investigation panel, none of which was noted by the Trust’s Patient Safety Summits .The matter was reported to the Coroner a year after Ida’s death by the family after the Trust took no action to do so, despite being on notice of failures in treatment from the HSIB report Ida’s harm was at no point categorised by the Trust as a harm event that caused “death”. 5. Trust figures to the Board provided in 2025 stated that there were no complaints over 6 months old when the Trust at the time of the inquest have not responded to [REDACTED] and [REDACTED]’s 1 June 2020 complaint. Together with the Trust’s failure to categorise Ida’s death as only “Moderate Harm” (see point 4 above) cause me also to have concern about the reliability of Trust’s data. B: Clinical Governance and Maternity Governance [Trust, ICB and DHSC] 6. I consider the clinical governance arrangements at the Trust require urgent review to ensure the appropriate personnel are in place, with the necessary training and skills to deliver robust clinical governance to ensure patient safety in maternity care. 7. As a result of the Trust’s deficient processes, the Trust did not undertake any examination of its own clinical governance processes, which were a principle area of concern and which was identified to the Trust five months before the inquest commenced. The Trust’s clinical governance arrangements were extracted piecemeal during the course of the inquest. The deficiencies included lack of version control and audit of documents, untrained staff, chaotic clinical governance arrangements, defensive attitudes and inappropriate self- congratulation. The clinicians’ reports to the inquest only answered the questions they were asked rather than trying to assist with a holistic view of the evidence, did not provide relevant information until it was extracted from the witness in testimony, that resulted in rolling disclosure of documents and additional witness evidence. This approach caused additional distress to the family who had to sit through an extended court hearing to address these issues 8. [REDACTED] is now Head of Compliance and Assurance at the Trust but that there has been no investigation into her role in respect of reneging on the Trust’s acceptance of the HSIB report at senior management level and with the family as was indicated by her approval of the July 2021 position statement. Similarly, [REDACTED] is now Head of Midwifery at the Trust and there has been no investigation in respect of her disputing the HSIB findings and submission of challenge to the HSIB report in Ida’s case. 9. All investigations conducted by the Trust to date in respect of Ida’s death have been unskilled, superficial, brief, failed to identify issues and left the family without answers and were all features identified by the 2015 Kirkup Report. In view of the continuing culture at the Trust, this cause a significant concern that issues of safety and safeguarding are not properly considered, transparently engaged with and then addressed formally in respect of a child fatality and serious injury by the Trust. 10. The Trust’s clinical governance capability has been the subject of repeated and often severe criticism in the Flynn Review 2009, Fielding Report 2010, Central Manchester Hospital Report 2011, Price Waterhouse Cooper 2012 and Kirkup Report 2015. [REDACTED] in his evidence to the inquest said that the Trust focus on process, which means that you can comply with the process requirements and still produce an inadequate investigation, rather than focussing on outcome, which measures the quality of the investigation and the patient experience. [REDACTED] noted that the Trusts culture impeded transparent and open investigation. I am told that the Trust now uses the PSIRF model and is to appoint 3 whole time equivalent Response Leads by 30 September 2025. However, I remain concerned that the Trust has not fully engaged with the duty of candour such that I am not satisfied that the work on PSIRF to date has truly addressed the issues in respect of Trust’s investigations. C. Mandatory Training, expired training and remedial training [Trust and ICB] 11. The Band 5 midwife supporting [REDACTED] in Labour had not undertaken her required mandatory training and this fact had not been provided and was only revealed at the inquest as part of the evidence of the Head of Midwifery in March 2025. I was also concerned to learn that in 2025 non-completion of mandatory training was still an issue as [REDACTED] had not completed her mandatory training. 12. It concerns me that the Trust do not have robust systems in place to ensure that any midwife who has not completed her mandatory training is subject to immediate action to ensure that all mandatory training is completed and is in date. 13. There was no remedial training was put in place for either the midwives involved in Ida’s delivery and resuscitation or for the paediatric SHO after Ida’s death. This raises a significant concern that the Trust do not operate a system of remedial training when this inquest has identified remedial training was required for [REDACTED], [REDACTED], [REDACTED] and [REDACTED]. D. Grading of harm for incident reporting: Babies who have sustained hypoxic brain injury and undergo cooling [Trust, ICB, DHSC, NHSE, [REDACTED]] 14. The Trust graded Ida’s level of harm as “moderate”, even after her death. This grading should have been adjusted to “severe” by the Trust before Ida was transferred to Royal Preston Hospital as the consultant paediatrician identified that she had sustained a severe hypoxic ischaemic encephalopathy due to fetal bradycardia. 15. The 2024 NHSE Learn from patient safety events (LFPSE) guidance that replaced the National Reporting and Learning System (NRLS) confirms that the recording and analysis of patient safety events that occur in healthcare support the NHS to improve learning from patient safety events to help make care safer. There is a significant risk that if reporting is graded on harm alone, clinical care that resulted in hypoxic brain damage during delivery and which was prevented by therapeutic cooling, will not adequately identify the problems that caused the harm during the delivery. 16. [REDACTED] confirmed that nationally there is inconsistency in categorisation of harm for babies who sustain a hypoxic injury due to fetal bradycardia in labour and who require cooling and clarification guidance would assist prevent further maternity deaths and ensure full and proper investigation of hypoxic injuries sustained in labour. E: Funding for MSNI [DHSC and [REDACTED], NHSE and ICB] 17. But for the HSIB investigation report into Ida’s death [REDACTED] admitted that Ida’s death due to failures by the Trust would never have come to light or resulted in an inquest. 18. The MSNI is now hosted by the CQC with funding secured for the next two years but no certainty as to ongoing funding after this date. These independent investigations by specialist skilled investigators into the most serious of events is an essential safeguard to the lives of mothers and unborn children. 19. Without an assurance that funding will continue beyond 2027 I am concerned that significant harm events to mothers and babies and deaths such as Ida’s will go unrecorded and lessons that should be learned to prevent future maternal and baby deaths will go unnoticed, and there will be a risk of future maternity deaths.
  21. News Article
    Two hospital trusts have recorded high adjusted mortality rates for five of the past seven years, according to HSJ analysis of maternity safety audit findings. The annual MBRRACE (Mothers and babies: reducing risk through audits and confidential enquiries) study of perinatal mortality and stillbirths compares adjusted death rates using a range of factors — such as health conditions, deprivation, and ethnicity — and then measures each hospital against a comparator group. A trust is given a “red” rating if its adjusted death rate is at least 5% above the average of its group of trusts with similar facilities and numbers of births. HSJ analysis of the seven years for which the audit has comparable data shows there are seven trusts that had at least three “red” ratings. Several of the trusts said they believed their case-mix and populations were not fully adjusted for. Some argue they take births where the baby has a very low chance of survival because of a heart or other condition, for example, and that this is not accounted for by MBRRACE. The MBRRACE spokesperson added: “It is essential that care providers review their own data alongside other sources and conduct systematic reviews of each death using the perinatal mortality review tool. We strongly recommend this for all providers.” Pauline McDonagh Hull, a research analyst at the University of Calgary in Canada, who led a similar review of audit ratings published in the Journal of Public Health, told HSJ: “MBRRACE recommended local reviews or investigations at all those falling into red or amber bands. We need to ask whether these have been taking place, what they found, and what, if any, changes were implemented, and if they haven’t been happening, why not? “Similarly, has MBBRACE-UK, NHS England, the Royal College of Obstetricians and Gynaecologists, the Care Quality Commission or anyone else followed up on these annual recommendations?” Read full story (paywalled) Source: HSJ, 28 March 2025
  22. News Article
    The healthcare watchdog has apologised over delays to the publication of its report into maternity services in Nottingham, which is subject of the largest inquiry of its kind in the NHS. Care Quality Commission (CQC) inspections - in June and July - found seven breaches of regulation in safe care and treatment at Nottingham University Hospitals (NUH) NHS Trust's two main hospitals. Overall, maternity services have been rated as requires improvement for being safe and well-led. Following criticism from Donna Ockenden, who is leading the review into maternity deaths and injuries at the trust, the CQC has admitted the report was not published "as soon after the inspection as it should have done". Following publication of its report, the CQC apologised for the delays, which senior midwife Ms Ockenden labelled "unacceptable" last month. "Due to a large-scale transformation programme at CQC, this report [was] not published as soon after the inspection as it should have done," a CQC spokesperson said. "The programme involved changes to the technology CQC uses but resulted in problems with the systems and processes rather than the intended benefits. The amount of time taken to publish this report falls far short of what people using services and the trust should be able to expect and the CQC apologises for this." Read full story Source: BBC News, 26 March 2025
  23. Content Article
    Some hospitals have established a preterm birth pathway to predict, prevent, and prepare for early births. This study reviewed and made suggestions on how best to implement the pathway. These included: better staff training on early birth and the pathway multidisciplinary preterm teams women-centered care.  Obstetricians, midwives, hospital managers, and professional bodies for maternity care could use the findings to improve care.  
  24. Content Article
    The biggest area of risk – in terms of lives lost and cost – involves NHS maternity units. Organisation upheaval must not distract us from what matters most, writes Jeremy Hunt, former health secretary. He highlights three key things that need to happen. First, it is essential that improving maternity safety is part of the new 10-year plan as it was in the last one. We also need a system to make sure that recommendations from public inquiries, the independent Health Services Safety Investigation Body (HSSIB) and coroners are actually implemented. There needs be a central repository of recommendations with public accountability as to who is responsible for implementing which ones by an agreed date. It is also critical to put in place a turnaround programme for the 10% of trusts where maternity safety is rated inadequate by the Care Quality Commission (CQC).  Finally – and most challengingly – we need a renewed focus on dismantling the blame culture that makes it difficult for clinicians to be open about mistakes and failures, and therefore make sure the system learns the necessary lessons.
  25. News Article
    By the entrance to Furness General Hospital in Barrow-in-Furness sits a sculpture of a moon with 11 stars. It is a memorial to the mother and babies who died unnecessarily due to poor care at the hospital between 2004 and 2013. When the memorial was unveiled in 2019, Aaron Cummins who is chief executive at University Hospitals of Morecambe Bay NHS Trust, which runs the hospital, said: "We will never forget what happened. We owe it to those who died to continually improve in everything that we do." Barely a month later, Sarah Robinson stepped into a birthing pool at the Royal Lancaster Infirmary, a hospital run by the same NHS trust. She was about to give birth to her second child. Within an hour, Ida Lock was born; within a week, she was dead. The inquest into Ida Lock's death, which concluded last week, exposed over five weeks why maternity services across England have long struggled to improve - and this one case holds a mirror to issues that appear to be prevalent across a number of trusts. 'That investigation, carried out by Dr Bill Kirkup and published in March 2015, found there had been a dysfunctional culture at Furness General, substandard clinical skills, poor risk assessments and a grossly deficient response to adverse incidents with a repeated failure to properly investigate cases and learn lessons. Morecambe Bay became a byword for poor maternity care and the trust promised to enact all 18 recommendations from the Kirkup review. And yet that never happened. Ida Lock's inquest began last month, more than five years after she died - the delay was down to several reasons, including its particular complexity. What emerged was just how profoundly many of those lessons had not been learned. Particularly egregious, says Ms Robinson, was a suggestion from a midwife – shortly after the birth - that Ida's poor condition was linked to her smoking, something Sarah had never done in her life. As the coroner found on Friday, Ida's death was wholly avoidable, caused by a failure to recognise that she was in distress prior to her birth, and then a botched resuscitation attempt after she was born. By the time she was transferred to a higher dependency unit, at the Royal Preston hospital, she had suffered a brain injury from which she could not recover. Having failed to deliver their daughter safely, Ida's parents would have expected that the trust would properly and openly investigate her death. Instead, they pursued an investigation that Carey Galbraith, the midwife who completed it, would later describe as "not worth the paper it was written on". They didn't take responsibility for their failings despite having an independent report from the Healthcare Safety Investigation Branch (HSIB). Clearly, the Morecambe Bay report was not, as was hoped, a line in the sand for maternity services across England, or a rallying cry for widespread improvements. As the inquest has shown, it did not even lead to sustained improvement at Morecambe Bay. Read full story Source: BBC News, 24 March 2025 Further reading: Ida Lock: Baby girl died from brain injury because midwives failed to provide basic care, coroner rules
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