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Found 65 results
  1. News Article
    The inquiry into Britain's worst maternity scandal is now reviewing 900 cases, a health minister has confirmed. The Ockenden Review, which was set up to examine baby deaths in the Shrewsbury and Telford Hospital Trust, was initially charged with examining 23 cases, but Nadine Dorries, a health minister, confirmed to the Commons that an additional 877 cases are being reviewed. A leaked report in November said a "toxic culture" stretching back 40 years reigned at the hospital trust as babies and mothers suffered avoidable deaths. The review will conclude at the end of the year. Jeremy Hunt, the former health secretary, said it was "deeply shocking" to hear of the new details and asked that the inquiry is "resolved as quickly as possible". Read full story Source: The Telegraph, 16 January 2020
  2. Content Article
    The report suggests strategies to prevent newborn falls in the hospital, whichl include: focusing efforts on providing support for exhausted parents during the critical time following the birth offering periods of rest for new parents whenever they are tired increasing the frequency of rounding when new mothers are breastfeeding promoting a midday break in visiting hours. In cases where a newborn fall event does occur, facilities should provide support to both injured newborns and any caregivers involved. In many cases, parents and other caregivers may benefit from counselling to help them better navigate the emotional turmoil that often follows these events.
  3. Content Article
    Recommendations include: assess patients for venous thromboembolism (VTE) risk with an easy to use automated scoring system provide the recommended prophylaxis regimen, depending on whether the mother is antepartum or postpartum reassesses the patient every 24 hours or upon the occurrence of a significant event, like surgery ensure that the mother is provided with appropriate VTE prevention education upon hospital discharge.
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  5. News Article
    Sick newborns in some areas of the UK are dying at twice the rate of seriously ill babies in other areas, a new report has revealed. The findings raise serious questions about the quality of care in some neonatal units, with experts warning action needs to be taken to tackle the “striking variation”. Across the country neonatal units are also short of at least 600 nurses with four in five failing to meet required safe staffing levels for specialist nurses. The regions with the highest mortality rate at 10 per cent were Staffordshire, Shropshire and the Black Country, where 107 babies died. This compared with a rate of 5 per cent in north central and northeast London. The Shropshire region includes the Shrewsbury and Telford Hospitals Trust, which is at the centre of the largest maternity scandal in the history of the NHS, with hundreds of alleged cases of poor care now under investigation. Dr Sam Oddie, a consultant neonatologist at Bradford Teaching Hospitals Trust and who led the work for the Royal College of Paediatrics and Child Health, said he was “surprised and disappointed” by the differences in death rates between units. “The mortality differences are very striking, with some units having a mortality rate twice that of the lowest. This variation in mortality is a basis for action by neonatal networks to ensure they are doing everything they can to make sure their mortality is as low as possible,” he said. Read full story Read MBBRACE-UK report Source: The Independent, 18 December 2019
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  8. Content Article
    Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each baby counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned. From 2015, they began collecting and analysing data from all UK units to identify lessons learned to improve future care. They will then be able to make recommendations on how to improve practice at a national level. This page brings together all of the information and resources about the Each baby counts programme.
  9. Content Article
    Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help.
  10. News Article
    An NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares. The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button. Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued. The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future." A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”. Read full story Source: The Independent, 10 December 2019
  11. News Article
    Maternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said. A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year. An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018. Read full story Source: The Independent, 6 December 2019
  12. News Article
    NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
  13. Content Article
    Key recommendations from report The creation of NHS-led Women’s Health Strategies. Young people should be educated from an early age about women’s health. The NHS website should become the world’s best source of information for girls, women and clinicians. To reduce health inequalities, all women should have access to and be provided with the information that they need to stay healthy. Access to the full range of contraception methods should be as easy as possible for all women. Post-pregnancy contraception should be a key part of the maternity pathway. Introduce mandated co-commissioning of SRH services across the UK. Increase public health and sexual health budgets in real terms. Women’s health one-stop clinics should be established in local community hubs and training on women’s health should be delivered to support primary and community care. All women should be able to access abortion care easily and without fear of penalties or harassment. End post-code lotteries in IVF treatment and offer all eligible women three full cycles of IVF. England, Wales and Northern Ireland must offer women the same opportunities for IVF treatment as in Scotland and follow the NICE Fertility Guideline which recommends that women under 40 should be offered three full cycles of IVF. Introduce a life course approach to preventing noncommunicable disease in women and their children supported by data collection before, during and after pregnancy. UK Governments should take strong action to improve the health of pregnant women and their babies. Improve identification of women at risk from mental and physical health issues with the six week postnatal check. End the data gender gap, End violence against girls and women via an improved collaborative approach, better IT systems and mandatory training with the NHS as an exemplar. Increase uptake in cervical screening amongst disadvantaged and marginalised women. Increase uptake in cervical screening by ending fragmentation and harnessing technologies. Improve early diagnosis and treatment of gynaecological cancers. Women’s health issues should be embedded in workplace policies. Appointment times at GP services should increase to 15 minutes. Increase awareness of pelvic floor dysfunction.
  14. News Article
    UK women face widespread barriers to essential healthcare services. A survey of over 3,000 women in the UK shows many are struggling to access basic healthcare services including contraception, abortion care and menopause support . The Royal College of Obstetricians and Gynaecologists (RCOG) calls for one-stop women’s health clinics to provide healthcare needs for women in one location and at one time. The RCOG launched a landmark report “Better for Women” – to improve the health and wellbeing of girls and women across their life course – in The House of Commons. The RCOG is calling for better joined up services, as part of its 'Better for Women' report. It emphasises the need for national strategies to meet the needs of girls and women across their life course – from adolescence, to the middle years and later life. Read full report
  15. News Article
    A health board criticised for severe maternity failings put too much emphasis on targets instead of patient safety, according to a new review of quality governance arrangements at Cwm Taf Morgannwg University. It found wider failings in Cwm Taf Morgannwg health board's governance. Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) also found a high level of risk to patient safety was accepted as the norm in some departments. The health board said work was under way to address the issues raised. The report was not an assessment of frontline care, but spoke to staff about procedures for reporting and learning from problems. It found Cwm Taf Morgannwg health board had not given enough attention to the safety of its services, in contrast to a strong focus on targets and financial controls. Read full story Source: BBC News, 19 November 2019
  16. News Article
    Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent. It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it". The trust apologised and said "a lot" had been done to address concerns. In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement. Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage. The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort". Read full story Source: BBC News, 20 November 2019
  17. News Article
    Hundreds of women left in debilitating pain by faulty transvaginal mesh devices have won a landmark case against multinational giant Johnson & Johnson. The Australian class action against companies owned by Johnson & Johnson was won on behalf of 1,350 women who had mesh and tape products implanted to treat pelvic prolapse or stress urinary incontinence, both common complications of childbirth. The devices all but ruined the lives of many. Women have been left in severe, debilitating and chronic pain, and often unable to have intercourse. The vast majority also suffered a significant psychological toll. The mesh eroded internally in many cases, has caused infections, multiple complications, and is near impossible to completely remove, Australia’s federal court has heard. The devices were not properly tested for safety before being allowed on to the Australian market, though Johnson & Johnson and the associated companies clearly knew the potential for serious complications. The companies were accused of launching a “tidal wave” of aggressive promotion at doctors, marketing the devices as cheap, simple to insert, and a relatively risk-free way to boost profits. All the while, their potential dangers were minimised, downplayed or ignored, both in communications to doctors and patients, the plaintiffs alleged. When patients complained of pain, they were frequently disbelieved. Read full story Source: The Guardian, 21 November 2019
  18. News Article
    The Care Quality Commission (CQC) issued a warning notice to the West Suffolk Hospital in Bury St Edmunds, which must improve by 31 January. It has not released details but the hospital said inspectors flagged up how it recorded observations and monitored women in its care. A hospital spokeswoman said: "We have taken this feedback seriously and are acting accordingly." She added: "Concerns have been raised about how we record patient observations after we have taken them, which are currently not in line with national guidance". "The CQC also identified that we should make changes to the way we monitor women in our care, again to bring us in line with national guidance". "We are making the necessary changes and the CQC is satisfied with the plans we have in place to make the improvements required." Read full story Source: BBC News, 21 November 2019
  19. News Article
    As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself. Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women." Read full story Source: The Independent, 20 November 2019
  20. News Article
    In March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua. The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale. James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families." Read full story Source: The Independent, 21 November 2019
  21. News Article
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service. Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger. Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming. Read full story Source: The Guardian, 2 November 2019
  22. News Article
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire. Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg. Dr Bill Kirkup says it suggests failure might be more widespread in the NHS. The surge in new cases follows the leak of an interim report last week. Read full story Source: BBC News, 27 November 2019
  23. News Article
    More than a third of maternity doctors are “burnt out,” and at risk of lacking empathy for the women in their care, researchers have warned. The study of more than 3,000 obstetricians and gynaecologists found high levels of long-term stress and overwork, especially among trainee medics. Researchers said the findings – from the largest UK study on the topic – were “very worrying,” with serious implications for patients. Overall, 36% of those surveyed met the criteria for “burnout,” which is associated with emotional exhaustion, lack of empathy and connection with others, researchers said. Medics who met the criteria for burnout were three times as likely to report anxiety, irritability and anger. They were also four times more likely than colleagues to practice “defensively”- meaning they tried to avoid difficult cases, or else carried out more interventions than necessary, for fear of error. Read full story Source: The Telegraph, 26 November 2019
  24. News Article
    Large numbers of previously missed abnormalities have been uncovered in the biggest review of smear tests undertaken since cervical cancer screening began in Ireland. The review led by the Royal College of Obstetricians and Gynaecologists in the UK has found hundreds of “discordant” results after re-examining the slides of over 1,000 women who had been tested for the disease under CervicalCheck, were given the all-clear and later developed cancer, according to an informed source. Discordant means the re-examination of the smear test by Royal College reviewers has produced a result that is different from the original finding by CervicalCheck. The extent of the individual divergences from the initial results is not yet known, but the review has found some cancers could have been prevented, it is understood. The college is due to submit an aggregate report on its findings to Minister for Health Simon Harris shortly. Read full story Source: The Irish Times
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