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Content Article
The Professional Standards Authority have published their annual performance review of the Nursing and Midwifery Council (NMC). The Nursing and Midwifery Council (NMC) regulates the practice of nurses and midwives in the UK, and nursing associates in England. For this review, the NMC met 11 out of 18 of our Standards of Good Regulation. These Standards provide the benchmark against which we review performance. Meeting or not meeting a Standard is not the full story about how a regulator is performing. Key findings and areas for improvement Response to whistleblowing disclosures The NMC has been working to respond to serious concerns raised in whistleblowing disclosures. It has commissioned three independent reviews, two of which had not been published by the time we completed our review. The published ICR made numerous critical findings about the NMC’s organisational culture, and the NMC accepted all its recommendations. We note that the concerns are serious, and we had regard to the findings of the published ICR where relevant, alongside the other evidence available to us. We will consider the findings of the other two reviews when they are available. Equality, Diversity and Inclusion (EDI) The whistleblowing concerns included concerns about discrimination and the organisational culture of the NMC. We saw that the NMC has processes in place to promote EDI, but given the findings of the ICR, we could not be assured that these processes were working effectively. The NMC has acknowledged that it needs to develop its capability in EDI, and has begun work on a range of improvement actions. We saw that the NMC’s standards and guidance promote non-discriminatory, respectful, compassionate, and kind care. However, we were not assured that the NMC has effectively embedded EDI into its work. Therefore Standard 3 was not met. Education quality assurance We noted some serious concerns about the NMC’s work to assure the quality of education and training. Having identified issues about a training provider’s compliance, the NMC carried out a mandatory self-reporting exercise where it required all training providers to send information about compliance with its standards. In our view, the need for such an exercise illustrated a failure of the NMC’s routine monitoring. The NMC had also carried out an internal review of its education quality assurance work, which identified a number of serious risks, and limitations on the NMC’s ability to mitigate them. The NMC started work on an improvement plan, but this was still in development by the end of our review period. Therefore Standard 9 was not met. Accuracy of the register Around 350 graduates from a university training course were added to the NMC’s register when they had not completed the required practice hours. When it became aware of the issue, the NMC contacted the affected graduates to request information about further practice learning they may have undertaken; most but not all had responded by the end of the review period. A number of other people may have joined the register fraudulently in relation to instances of large-scale fraudulent applications. The NMC is investigating these matters and has taken steps to improve its fraud prevention processes. However, maintaining an accurate register is a core function of a regulator, and a large number of people were added to the NMC’s register without meeting its requirements. Therefore Standard 10 was not met. Fitness to Practise The NMC is still taking too long to deal with fitness to practise cases. It has been working to an action plan to clear its backlog but had made only limited progress during the review period, partly because it had received more referrals than expected. Therefore Standard 15 was not met. Concerns about the NMC’s safeguarding capability were identified through the whistleblowing disclosures. Safeguarding is identified as the NMC’s highest strategic risk, and it has taken action to improve its ability to detect and address cases. However, an internal audit identified that there had been cases where the NMC had not taken action that was necessary from a safeguarding perspective. Even a small number of safeguarding failings could amount to a serious risk to the public. Therefore Standard 17 was not met. The evidence we saw from our audit of a sample of cases did not give us serious concerns about the NMC’s routine decision-making. One of the independent reviews into whistleblowing disclosures will be reviewing a sample of fitness to practise cases, and we will consider the outcomes of the review when available. -
Content Article
Each year since May 2023 the Sands & Tommy’s Joint Policy Unit have published an annual report setting out the extent of pregnancy and baby deaths across the UK. This year’s report argues that progress made to date falls short of what is needed to stop babies dying every day in the UK, and that unacceptable inequalities in pregnancy and baby loss persist despite continued calls for change. It estimates that at least 2,500 fewer babies – the equivalent of around 100 primary school classrooms - would have died since 2018 if the government had achieved its ambition of halving the 2010 rates of stillbirth, neonatal and maternal deaths in England. The report draws on the latest data from MBRRACE-UK, which shows that the gap continues to grow between neonatal death rates in the most deprived areas and those in the least deprived areas of the UK. It highlights that the stillbirth rate among babies of Asian ethnicity has risen sharply, and Black babies are still twice as likely as White babies to be stillborn. It includes 10 key actions for policymakers Renew commitments to save babies’ lives. Specifically, a stillbirth rate of 2.0 stillbirths, and a neonatal mortality rate of 0.5 neonatal deaths for babies born at 24 weeks’ gestation and over (per 1,000 live births). A preterm birth rate of 6.0%. Count miscarriages in the UK. The number and rate of miscarriages are not reported across the UK or for any individual nation. All UK governments should set up routine data collection on miscarriage. Take coordinated and meaningful action to eliminate inequalities. There are a range of policy areas where specific action is needed, including: understanding whether current efforts to reduce inequalities are working, and a comprehensive review of translation and interpreting services in maternity and neonatal care. Strengthen national leadership to make progress on the safety of maternity and neonatal services. Clarify the workforce needed to deliver safe care. Future development of the workforce must move away from a binary debate focussed on whether we do or don’t have enough staff and focus on the staffing requirements needed to deliver safe care, in line with nationally-agreed standards. Put the resources needed in place to deliver safe care. More investment is needed to improve the safety and quality of services if the government is going to deliver on its commitments to reduce rates of stillbirth and neonatal death and eliminate inequalities. Make informed choice a reality. Everyone should receive personalised care, know what they are entitled to, such as their birth choices, and services need the resources and operational capacity to provide this. Address unwarranted variation in care. Too often babies are dying because of care that is not in line with nationally-agreed standards. We need clarity on how national guidance is applied and clear national standards to improve the consistency of service provision. Ensure lessons are learned when babies die. The NHS is still not properly learning lessons when babies die or listening to the experiences of bereaved families to improve care in the future. There must be more robust oversight of the implementation of actions that are identified by reviews and investigations. Prioritise pregnancy and baby loss in research. This requires a broad range of research topics, the involvement of bereaved parents and communities, and a strong connection with policy and practice. -
News Article
Baby death NHS trust reaches 'turning point'
Patient Safety Learning posted a news article in News
Two maternity units in Kent have shown signs of improvements three years after a damning independent review found up to 45 babies might have survived if they had received better care, a report has said. The Care Quality Commission (CQC) report rated maternity services at William Harvey Hospital in Ashford and Queen Elizabeth The Queen Mother Hospital in Margate as good, two years after they were downgraded to inadequate. The CQC said "significant improvements" had been made at both units to safety, leadership, culture, the environment and staffing levels. Tracey Fletcher, chief executive of East Kent Hospitals University NHS Foundation Trust, said the report was "an important milestone in our continuing work to improve our services". Serena Coleman, CQC's deputy director of operations in Kent, said: "We found significant improvements and a better quality service for women, people using the service and their babies. "This turnaround in ratings across both services demonstrates what can be achieved with strong and capable leaders who focus on an inclusive and positive culture." Kaye Wilson, chief midwife for the South East at NHS England, said: "This report marks a turning point for services at East Kent and is the result of the commitment, determination and sheer hard work of midwives, obstetricians and the whole maternity team." Read full story Source: BBC News,15 May 2025 -
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.- Posted
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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.- Posted
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Event
untilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. In this webinar we will explore factors affecting the delivery of safe care in midwifery units following the analysis of 92 randomly selected cases where care had been given at some time during labour on a birth centre. Register for the webinar -
News Article
Texas charges midwife in first arrest under state’s abortion ban
Patient Safety Learning posted a news article in News
A Houston-area midwife was arrested for providing illegal abortions, Texas Attorney General Ken Paxton (R) said Monday, marking the first criminal charges under the state’s near-total abortion ban. Maria Margarita Rojas, 49, was charged with the illegal performance of an abortion and practicing medicine without a license, Paxton’s office said in a news release. Rojas owned and operated health clinics in Waller, Cypress and Spring, Paxton’s office said. Her facilities employed unlicensed people who presented themselves as medical professionals, officials alleged. Performing an abortion in Texas is punishable by up to life in prison and up to $100,000 in civil penalties. Abortions are only permitted when a pregnant woman is at risk of death or “substantial impairment of a major bodily function.” The law targets anyone who performs or helps set up an illegal abortion, including people who facilitate the distribution of abortion pills. Women seeking abortions can’t be charged under the state’s law. “In Texas, life is sacred,” Paxton said in a statement Monday. “I will always do everything in my power to protect the unborn, defend our state’s pro-life laws, and work to ensure that unlicensed individuals endangering the lives of women by performing illegal abortions are fully prosecuted. Texas law protecting life is clear, and we will hold those who violate it accountable.” Marc Hearron, interim associate director of ligation at the Center for Reproductive Rights, an organization that aims to protect reproductive rights, condemned Paxton’s efforts to ban abortions. “While details of this case remain unclear, we know that Texas officials have been trying every which way to terrify healthcare practitioners from providing care and to trap Texans,” Hearron said in a statement. “Their ultimate goal is to end abortion access for all Texans entirely — and they will throw people in jail to get there.” Read full story (paywalled) Source: Washington Post, 18 March 2025 -
News Article
Precautions could have stopped baby deaths
Patient Safety Learning posted a news article in News
"Reasonable precautions" could have prevented the deaths of three newborn babies, a fatal accident inquiry has found. Leo Lamont, Ellie McCormick and Mira-Belle Bosch all died within hours of their births in two Lanarkshire hospitals, in 2019 and 2021. The report found all three deaths could "realistically" have been avoided had different advice been given by midwives or procedures followed. The McCormick family said they could "never have imagined" the amount of failures that led to their daughter's death and called it a "catalogue of errors". The inquiry ruled "defects" within the system contributed to each death, including that there was a "lack of an effective means" to highlight risks in one of the pregnancies and that midwives had no guidance to assess preterm labour symptoms. Sheriff Principal Aisha Anwar KC made 11 recommendations for the future, including creating a "trigger list" to identify and assess early labour symptoms. Among these are reviewing electronic patient information records to improve alerts for at risk mothers, and having a direct telephone line to each maternity unit in Scotland for ambulance crews. In a statement, the McCormick family said: "The family could simply never have imagined the scale of both the individual and systems failures that came to light during the inquiry. "What seemed to be flaws with the electronic system of record keeping actually turned out to be a catalogue of errors with numerous opportunities to avoid the tragic outcome that followed." Read full story Source: BBC News, 18 March 2025- Posted
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Two women who police allege practised as unregistered midwives have been charged with manslaughter after a baby died after a home birth on the New South Wales mid north coast. The women, aged 41 and 51, appeared in Coffs Harbour local court on Wednesday in relation to the newborn boy’s death in 2022. Emergency services were called to a home in Karangi, north-west of Coffs Harbour, when the baby was unresponsive after the home birth on 11 September 2022, NSW police said in a statement. Paramedics treated the baby before he was airlifted to Coffs Harbour base hospital where he died. Police allege the younger woman was an unregistered midwife at the time of the birth while the older woman held no medical qualifications and had been practising unregistered home-birth midwifery. Read full story Source: The Guardian, 13 March 2025 -
News Article
Scandal-hit nursing regulator accused of covering up critical internal review
Patient_Safety_Learning posted a news article in News
Fresh calls have been made for a parliamentary inquiry into the Nursing and Midwifery Council – which is responsible for overseeing nearly 800,000 nurses, midwives and nursing associates in the UK – after it refused to publish the results of an internal review highlighting new failures to protect the public. Senior staff at the NMC carried out an investigation this year into how the regulator had handled dozens of serious allegations against nurses and midwives after whistleblowers raised concerns last year. Read full story Source: Independent, 30 December 2024 -
News Article
Hospital covered up baby’s death, says senior coroner
Patient Safety Learning posted a news article in News
A senior coroner has accused Chelsea and Westminster Hospital of a cover-up over the death of a baby who died when midwives failed to act on clear signs that his mother was in distress. Elton Deutekom was pronounced dead 37 minutes after his birth in January 2022. During labour his mother had a placental abruption — when some or all of the placenta separates from the wall of the womb. This was not picked up by her care team, and Elton was starved of oxygen. Doctors at the west London hospital did not refer the incident to the coroner and wrongly told the NHS’s healthcare safety investigation branch (HSIB) that Elton had been stillborn and no investigation was required, an inquest into his death was told. It was not until his parents learnt of this anomaly in the records that an investigation was carried out by the HSIB, which uncovered serious failings in his care. Professor Fiona Wilcox, the senior coroner, said: “I need to say this on the record and in public — this feels like there has been an attempt at a cover-up.” She later repeated: “I am concerned there is an element of cover-up in this death. I will say it categorically.” Concluding that Elton had died from natural causes to which neglect contributed, the coroner said there had been “gross” failings in his care. She said that if the midwives had adequately monitored his heart rate, acknowledged his mother’s pain and recognised hypoxia — oxygen deficiency — he would have been delivered earlier and would have survived. Read full story (paywalled) Source: The Times, 21 November 2024- Posted
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Content Article
This initiative aims to improve the identification and treatment of perinatal mental health conditions (PMHC) for all patients throughout the entire perinatal period. For the purposes of the bundle, PMHC includes: mood, anxiety, and anxiety-related disorders that occur during pregnancy or within one year of delivery, including conditions that may have started prior to conception. -
News Article
‘Culture of bullying and undermining’ uncovered in trust’s maternity service
Patient Safety Learning posted a news article in News
Trainee midwives at a struggling trust have raised serious concerns about bullying and feeling afraid to speak up, an NHS England report has revealed. Experiences of pre-registration midwifery trainees at Birmingham Heartlands Hospital and Good Hope Hospital, part of University Hospitals Birmingham Foundation Trust, are detailed in a recent NHS England workforce, education and training report following a visit in January. The report said learners at BHH reported a “concerning culture of bullying and undermining”, with some midwives displaying hostility and rudeness, and one student constantly feeling like they were in “fight or flight mode”. At GHH, students were aware how to raise concerns but described it as a “waste of time”, telling NHSE qualified midwives had informed them they frequently raised concerns about staffing levels without these being resolved. Meanwhile, at BHH trainees said lack of action taken when they tried to raise concerns had created an environment where learners were reluctant to voice fears about patients or seek guidance on patient care. The NHSE report said students provided multiple instances of trying to raise concerns which were either not acted on or they experienced repercussions for having attempted to speak up. One person expressed concerns about a woman who had experienced severe bleeding following birth but their supervising midwife dismissed their concern. They then escalated the matter to another staff member and was taken more seriously, but as a result, the student said their supervising midwife “made my life hell” for the rest of the shift. NHSE said it heard examples where midwives made derogatory comments about students in public, including about one person’s weight, which caused them to leave the building in tears. Read full story (paywalled) Source: HSJ, 24 May 2024 -
Event
RCM conference 2024
Patient Safety Learning posted an event in Community Calendar
untilEnergising excellence. Bringing research, education, practice and leadership to life The RCM conference is back for 2024. Professional and educational standards of proficiencies have made clear the importance of midwives working across the professional pillars of the profession: research, education, clinical practice and leadership. Safe and effective care needs an evidence base from research, which is then disseminated and supported through education and strategically implemented into clinical practice and sustained through effective leadership. Furthermore, understanding midwifery professional pillars is relevant for promoting career pathways and ensuring professional recognition alongside our multi-disciplinary colleagues. Register -
Content Article
.As healthcare organisations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. This handbook was published by Healthcare Improvement Scotland to support NHS board maternity services to: understand the importance of safety culture. undertake a patient safety climate survey. understand what the survey results are telling them. develop an improvement plan to address areas that have been highlighted. It includes: the Maternity Services Patient Safety Survey. template letters for NHS boards to adapt for local use. an example improvement plan template.- Posted
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On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy. Coroner's Matters of Concern: The Inquest was held one year after Bethan Naomi Harris's death. During the course of the oral evidence it emerged that several, in my mind important, learning issues had not been addressed. There were issues relating to handover of patients to midwives and at the time of Inquest there had been no further specific training in relation to handover. Indeed it was stated that the process in place at the time of Bethan's delivery still pertained without alteration. This represented a risk to patients. At the time of Inquest a team debrief, which I consider to be a source of learning to reduce the risk of serious incident in future was still outstanding. There was little evidence from the oral evidence given that any effective reflection, reflective discussions or learning had taken place subsequent to Bethan's birth and then death. I consider it important that organisations seek to ensure individual and collective reflection to seek to avoid repetition. The evidence for this, one year on, was lacking. St George's University Hospitals response.- Posted
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Content Article
For Every Pregnancy campaign (NMC)
Patient-Safety-Learning posted an article in Maternity
For Every Pregnancy is a campaign by the Nursing & Midwifery Council. It aims to show that each pregnancy is unique, and whatever stage you're at, your midwife team should be right alongside you. The campaign includes posters and videos aimed at outlining the standards of care pregnant women and birthing people can expect and the importance of shared decision making.- Posted
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This briefing was commissioned by the Maternal Mental Health Alliance who are dedicated to ensuring all women, babies and their families across the UK have access to compassionate care and high-quality support for their mental health during pregnancy and after birth. One woman in five experiences a mental health problem during pregnancy or after they have given birth. Maternal mental health problems can have a devastating impact on the women affected and their families. NICE guidance states that perinatal mental health problems always require a speedy and effective response, including rapid access to psychological therapies when they are needed. Integrated care systems (ICSs) have a unique opportunity to ensure that all women who need support for their mental health during the perinatal period get the right level of help at the right time, close to home. Key points Maternal mental health problems are common and can be extremely serious. Timely access to effective help can make a big difference to long-term health outcomes for mothers and generations to come Integrated care systems can ensure that comprehensive and evidence-based support is provided to women and birthing people during the perinatal period Maternal mental health care must be developed equitably, adapting to the needs of groups of women with higher risk and poorer access to effective support Universal services – midwifery, general practice, and health visiting – are vital to identify needs and provide timely support Access to NHS Talking Therapies is essential for women with many diagnosable mental health difficulties during the perinatal period Specialist community perinatal mental health services are a priority for the NHS Long Term Plan and can meet the needs of women with more serious and complex conditions Adequate provision of specialist Mother and Baby Inpatient Units prevents women being separated from their babies if they need to be admitted to hospital The voluntary sector, including peer support, plays a vital role and needs to be commissioned and properly funded- Posted
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Content Article
The aim of the study was to explore the factors that affect the safety attitude and teamwork climate of Cyprus maternity units and Cypriot midwives. The study found that the safety climate in the maternity settings was negative across all six safety climate domains examined. The higher mean total score on team work and safety climate in the more experienced group of midwives is a predominant finding for the maternity units of Cyprus. It could be suggested that younger midwives need more support and teamwork practice, in a friendly environment, to enhance the safety and teamwork climate through experience and self-confidence. -
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This report by the Royal College of Midwives (RCM) highlights the impact of midwifery staffing shortages on women. It looks at historical failures to invest appropriately in maternity services and talks about a mounting maternity crisis, drawing attention to Care Quality Commission inspections of maternity services that are identifying concerns around safety directly linked to staffing shortages. According to the report’s findings, if the number of NHS midwives in England had risen at the same pace as the overall health service workforce since the last general election, there would be no midwife shortage; there would be 3,100 more midwives in the NHS, rather than having a shortfall of 2,500 full-time midwives. The RCM published the results of a survey last month which showed that midwives give 100,000 hours of free labour to the NHS per week to ensure safe care for women. It also showed that staffing levels were repeatedly cited as cause for concern around the safety of care, and that midwives and maternity support workers are exhausted and burnt out. -
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Founded by psychotherapist Rebecca Howard, ShinyMind's story has been a journey of creating an evidence-based mental health and wellbeing resource that people can trust to help them think well, feel well and be well.Rebecca believes everyone has the right to good mental health and access to support whenever they need it – and so ShinyMind’s journey began, to empower people, eradicate stigma and help as many people as we can shine their brightest.- Posted
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- Mental health
- Midwife
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#Saynotobullyinginmidwifery
Patient_Safety_Learning posted an article in Maternity
*Trigger warning: This report contains accounts of bullying behaviours and consequences and may trigger those who have experiences of bullying. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. In the numerous accounts shared all areas of the system from CQC, CEO, HR, midwifery management, universities and the unions are described as being complicit, inadequate, disinterested and even corrupt. Accounts also refer to: Unsafe work environments Exit interviews not being performed, recorded or acted upon Staff not being valued Whistle-blowers being demonised until they leave Health and safety issues and truly evidence-based practice ignored with no lessons learned. To order your copy, follow the link below. -
Content Article
Reducing inequalities in maternal health care in England is an important policy aim. One part of achieving that is to ensure that women from Black, Asian and minority ethnic communities, as well as women from the most deprived areas, see the same midwife or midwifery team throughout their pregnancy and postnatal period. Emma Dodsworth takes a closer look at the data to reveal what progress is being made on this.- Posted
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- Health inequalities
- Midwife
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Content Article
Reducing inequalities in maternal healthcare in England is an important policy aim. One part of achieving that is to ensure that women from Black, Asian and minority ethnic communities, as well as women from the most deprived areas, see the same midwife or midwifery team throughout their pregnancy and postnatal period. Emma Dodsworth takes a closer look at the data to reveal what progress is being made on this. -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jenny talks about the challenge of keeping up with and prioritising new guidance and the need to streamline recommendations to ensure they are implemented efficiently. She also discusses the importance of getting the basics, like staffing levels, right and how sea swimming has influenced how she sees patient safety.- Posted
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- Clinical governance
- Quality improvement
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