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Findings For healthcare staff, carrying out a robust assessment of risk factors for VTE is challenging, particularly in the complex and busy environment of antenatal clinics, the labour ward and on postnatal wards. Multiple competing demands, exacerbated by distractions and interruptions, mean healthcare professionals are constantly having to balance risk and safety for the pregnant women/pregnant people they care for and are trading off the thoroughness of assessments to improve efficiency. Midwives are asked to complete a number of risk assessments and screening tools to assess pregnant women’s/pregnant people’s risk at their first antenatal appointment (known as the booking appointment). However, the time needed to carry out these risks assessments may not be reflected in the time allocated for appointments. Risk assessments and screening tools are not all designed and presented in a consistent and logical way that would aid staff in completing the task. Assessment of VTE risk factors should take place routinely due to body changes in pregnancy and increased risk of VTE. Although assessing VTE risk is important, it is a relatively rare condition and there are a number of other competing risks that may take priority. Staff do not always involve pregnant women and pregnant people in, or discuss with them, the assessment of their risk factors for VTE. This means pregnant women and pregnant people may not be aware of the signs and symptoms of a possible VTE. The importance of knowing the signs and symptoms of VTE may not be fully understood or prioritised by pregnant women and pregnant people who may have other competing concerns and questions about their antenatal and postnatal care. National guidance recommends that assessment of VTE risk factors should be repeated when a pregnant woman/pregnant person presents with an ‘intercurrent problem’ (a new health issue which may or may not be related to the pregnancy). However, not all healthcare professionals understand the meaning of ‘intercurrent problem’ and therefore opportunities to reassess risk factors are missed. There is a mix of paper-based and electronic record keeping in antenatal and postnatal care. Electronic records systems may lack interoperability and suffer from poor connectivity which limits the ability of staff to access all the data, information, and knowledge they need at the time of assessment. Recommendations by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) for the development of a tool to make the current assessment of VTE risk factors simpler and more reproducible, have not been acted on. Safety observations It may be beneficial for organisations to consider guidance, such as the ‘principles for effectiveness and usability’ provided by the Chartered Institute of Ergonomics and Human Factors, when developing risk assessment tools. The aim being to ensure assessments are simple to use and therefore staff being more likely to do them thoroughly and avoid tick-box fatigue. It may be beneficial for organisations that make recommendations to improve the safety and care of pregnant women and pregnant people during their pregnancy and up to 6 weeks after birth, to have a process for reporting on responses to their recommendations. This would support transparency, making it easy to see what has been achieved and what remains outstanding. The aim being to enable tracking of the implementation of actions designed to improve safety and outcomes to ensure they happen. It may be beneficial if future research or funding is directed towards identifying the evidence base for the prescribing of low-molecular-weight heparin for venous thromboembolism risk in pregnancy and the first 6 weeks after birth. This will support the production of evidence-based clinical guidelines for the care and treatment of pregnant women and pregnant people at risk of VTE to ensure it is safe and effective.

Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete. Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common in the ‘retained foreign objects’ category. The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found. Safety recommendations HSIB made the following safety recommendation to NHS England and NHS Improvement as a result of this investigation. It is recommended that NHS England/Improvement carries out its intention to commission and publish an independent evaluation of its alternative design for swabs and tampons. The evaluation should also consider other solutions or technologies and include usability, cost/benefit analysis and the impact on reducing harm. NHS England and NHS Improvement response The Patient Safety team at NHS England and NHS Improvement is pleased to confirm that in line with its stated intention it had already commissioned a first stage independent evaluation of a proposed new design for swabs and tampons used in healthcare maternity services. Whilst it would not be feasible to commission an evaluation of other solutions or technologies that have not yet been well developed, further independent evaluation to compare this proposed design with other available solutions, and to evaluate potential cost benefit and impact analyses will be considered, conducted and published, should final prototypes prove possible to manufacture to the required specification and standards, and before any staged roll-out is considered. This response was received on 15 July 2020.