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Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients.

During the initial impact of the COVID-19 pandemic, the Government recognised that a key enabler would be to increase capacity within the NHS, ensuring that enough acute beds were available to cope with the rising tide of patients. An important policy priority has been to ensure the safe discharge of patients back into their home or, where appropriate, into a placement with a community provider. While there were already pathways in place to accelerate this process, responding to the pandemic required a significant acceleration of hospital discharges. Hospital discharges are complex. To enable a safe and timely transfer of care, they require good co-ordination between hospital and community staff to arrange clinical assessments and to equip the home or community setting with the appropriate equipment and care plans. In this submission to the Inquiry, Patient Safety Learning and CECOPS focus on: Rapid hospital discharge - considering the challenges to this caused by the pandemic, the importance of interoperability in overcoming these, preventing care homes and nursing homes becoming vectors of transmission and harnessing digital technologies, such as an app, to assist hospital discharges. Community support - as the rate of hospital discharges significantly increases, the need to consider the availability of Personal Protective Equipment supplies, access to and guidance on supportive equipment and technologies and other pressures that will need to be met by community support services. In the concluding comments the submission sets out an eight-point action plan required to tackle this issue: A model of demand to inform hospital discharge and planning of community and care services New agile ways of working using digital technologies. An improved cross health and social care information system is imperative to ensure safe transfers of care Strengthened cross-sector leadership and communication with clinical teams and patients and families The provision of equipment services addressed urgently - to support hospital discharge and prevent admissions i.e. wheelchair, prosthetic, orthotic and equipment services Integration of planning and service delivery across sectors with the right leadership, the ability and capacity at a local level to streamline services and procurement to the needs of patients, families, and care providers Innovation in the development of safe transfers of care. We must adapt the traditional bureaucratic processes and regulatory framework to ensure that the needs of patients are met speedily Financial support to ensure that there is capacity to provide community-based care The safety of patients at the core of all plans and service delivery. All plans should include how the safety of patients is being prioritised. References [1] UK Parliament, Delivering Core NHS and Care Services during the Pandemic and Beyond, Last Accessed 7 May 2020. https://committees.parliament.uk/work/277/delivering-core-nhs-and-care-services-during-the-pandemic-and-beyond/ [2] UK Parliament, Call for evidence: Delivering Core NHS and Care Services during the Pandemic and Beyond, Last Accessed 29 April 2020. https://committees.parliament.uk/call-for-evidence/131/delivering-core-nhs-and-care-services-during-the-pandemic-and-beyond/

This HSIB summary report provides an overview of: the referrals caseload under the maternity investigations programme for East Kent Hospitals University NHS Foundation Trust the themes which were identified as indicative of patient safety risk to mothers and babies the engagement and escalation process that HSIB undertook with the trust and the wider system in response.

This report will set-out our family engagement process. It will also summarise the feedback received to date from the families who have been involved in HSIB investigations. The purpose is to for HSIB to share their family engagement process with other healthcare organisations involved in patient safety investigations and raise awareness of the value of an effective family engagement process in such investigations. The report will: Describe HSIB’s approach to family engagement in our investigations and what has informed our practice. Describe what has worked well in our approach to family engagement. Summarise what families and staff tell us about our approach. Explain what we have learned and plans for future work.

Recommendations Human factors and behaviour: Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level. Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes. Workload and workforce challenges: Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population. This tool should complement the midwifery acuity tools currently implemented nationally. Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce. Communication: All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call. This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.

Key points Pregnant women do not appear to be more susceptible to the consequences of coronavirus than the general population and there is no evidence that the virus can pass to a baby during pregnancy. As a precautionary approach, pregnant women with suspected or confirmed coronavirus when they go into labour are being advised to attend an obstetric unit for birth but their birth plan should be followed as closely as possible. At the moment there is no evidence that the virus can be carried in breastmilk, so it is felt the benefits of breastfeeding outweigh any potential risks of transmission of coronavirus through breastmilk.

The story so far... We investigate an incident to collect facts that will prevent the incident from occurring again (see 'Why investigate?' blog). Facts collected by two or more investigators, with enough time away from the ‘day job’, tend to be of better quality than a single person fitting the investigation in and around their other duties (see 'Who should investigate?' blog). Human factors is a science done by science types who are trained in understanding how the limited ‘cave dweller’ tries to cope with their environment. Human factors types are not likely to have the title ‘Captain’ and have not just landed at Stansted (see 'Human factors' blog). Facts are our friend as they allow us to tell people why an incident occurred and, if those facts are accurate, allow us to do an intervention that will prevent the incident occurring again (see 'Where do facts come from?' blog). Good facts and great remedies allow us then to monitor the success of the intervention. But again, we are getting ahead of ourselves by talking about interventions. Sorry. At this stage it might be worth thinking about what we do with all those facts, how we see patterns in the data, what a good intervention might look like, and how and when we monitor success. As we have seen previously, there are four principal areas where facts come from: the human, the equipment, the environment and the system of working. How the investigation is conducted and by whom, and as we shall see ‘when’, affects these four principal areas of investigation and the three methods of intervention. So, four areas of investigation with facts emerging from many different sources: from inside the witness’s mind, from ward records, from engineering logs, etc. How these facts come together to form a big picture needs to be considered in terms of the intervention. A later blog will explain these interventions (after we discuss data and analysis – yay statistics), but for now it’s worth saying the three interventions are called ‘the three ‘Es’. Luckily the three words all start with the letter E so it makes sense. Engineering – The most effective intervention, as the machine keeps the cave dweller from making mistakes. Enforcement – Where someone polices the method of working or the equipment used, in a given environment. Education – the least effective method, which relies on a training course or a poster. “Don’t operate on the wrong side of a patient”. Well I never, what a useful reminder in a theatre. My favourite was at a rail depot. A poster (1 of 80 in the area) said. “Be alert and check the doors”. Really closing the train doors is a good idea… More in the intervention blogs. The why, the who, the what data collected will affect the quality of the facts. The facts collected determine the intervention chosen. The monitoring of success of the intervention is, perhaps, determined by the original hypothesis of the investigator, very early on in the investigation. We may do a blog on bias in investigations. A word of caution. You don’t always do an intervention. ‘Eek’ I hear screamed from every trust. This is because, as we have discussed, an incident is a rare random event with multiple causes. Sometimes an incident, or series of incidents, have occurred due to the random nature of humans and an emerging pattern of data is thought to have been found. This pattern, and these series of events, are, however, just random. So, very early on in this blog, I introduce the idea that ‘when’ an intervention might occur might be never. An example… Lots of crashes occurred along a three mile stretch of road. Detailed investigations revealed no pattern in any of the crash’s causation. The local authority had over £3 million to spend and was determined to spend it (they rightly want to keep their community safe). Well what intervention would you do given that there is no pattern? There is no consistency in the facts and the only pattern might possibly be in the investigators' minds. Given accidents are rare random events, if you do an intervention will it not make it worse? If it makes it worse, how do you reconcile your ‘no pattern data’? A comment was made by the local authority that suggested a pattern existed and we were not good at investigations and human factors. We reviewed the data again and conducted interviews with those involved (at our own expense). Indeed, there was perhaps a pattern. If you were female (most were), you were travelling north (most were), you were in the early stages of pregnancy (most were) – you appear to be involved in a crash. We noted this at home visits and it’s not recorded in the police data. Upon reporting back, the local authority understood that incidents are indeed rare random events and sometimes data emerges with no explanation. The comment from the authority – “So the only intervention is planned parenthood advice a few days before undertaking any northbound journey?” Indeed, that’s the correct conclusion for the data. No intervention was undertaken, and seven years later no incidents have occurred, and we understand the northbound mummies and babies are doing fine. The local authority remains a client after 18 years. It might be the case that (as my reviewer points out) that “maybe there was a factor there, but it went away without intervention (sleepwalking cattle randomly moved to another field further from the road)”. Hopefully, that should show the connection between the philosophy of data collection, its method of collection and by who, and how it affects the intervention and prevention. Also, the benefits of planned parenthood when travelling northbound. Hopefully, I’ve rounded up the last four blogs. So it’s now time to look at the when; like parenthood, it affects the outcomes too! When to investigate? When to investigate is determined by the facts you want to collect, where those facts come from and whether those facts are time sensitive, and your availability and the accessibility of the location. In broad terms, the ‘when’ is affected by two types of evidence: physical stuff and human witness stuff. Physical evidence Let’s start with a photograph. (Warning the image below contains graphic depictions of an older man in shorts!) Image 1: Older man finds the remains of an aircraft converted to a bar and restaurant. Copyright: User Perspective Ltd. Recovering engineering or physical evidence is less time sensitive than information from witnesses. Ward records can last a long time and engineering logs can as well. If you collect evidence from CCTV – that has a life span of 30 days. Generally, in medicine physical evidence is not time sensitive. However, like the image above, it shows that if you leave evidence for long enough someone will change it. In this case they make it into a restaurant. I eat elsewhere as I was sure a fellow human factor person was looking for the crash site! Human stuff – witnesses Most of the facts you collect come from witnesses, aka humans, aka cave dwellers. As we shall see in the ‘how to interview’ blogs, the facts are contained in the mind and it’s not easy to get them out. As you can see in Image 2 below, the decline in the availability of facts is very severe after 20 minutes. In later blogs we can discuss how to interview witnesses and how to get good quality data. Image 2: The Forgetting curve 1885. Copyright: User Perspective and HM Government (for this version). The important bit now is to think about the basic processes of human memory, which are: Perception – information gets into the mind. Encoding – its related to other facts and ‘digitised’. Storage – we need to keep it somewhere. Retrieval. Unless it can be extracted, it’s not useful. Each of these stages is associated with a decline in the quality of data and its retrieval is based on the ability of (in this case) the interviewer extracting it. As we are talking about when, the important thing is to get to those memories as quickly as possible and, certainly in medicine, to ensure that witnesses don’t get to chat to each other. If you want evidence from humans – get it quickly and ensure they don’t talk to each other. How quickly? It’s called the golden 24 hours in accident investigation – even though the graph from 1885 suggests a lot shorter time span. Incidentally, the person(s) reporting the incident needs acknowledgement a lot quicker than the 24 hours. Your availability and access Ideally you are a human factors person with a ‘go bag’. I’ve several ‘go bags’ that contain equipment needed for each domain (road, rail, security) I work in. The road one has green high vis, the rail has orange. The security one has assorted passes and body armour. This may be different in medicine. You might not be the first person called, and you work shifts, the chances of a call in the middle of the night is most likely rare. In other domains access is aided by blue lights and the possibility of handcuffs. Healthcare is different – remember these blogs are about prevention rather than prosecution. However, the point is that every second counts and the sooner you are there the better the data. Summary The facts you collect, how those facts are collected, and by who and when, affects the conclusions you can draw about the incident. Physical data lasts longer than human memory data but, as the picture of the ‘converted’ aircraft shows – things change. Who and when the facts are collected affects the interventions you can use, and the reliability of testing those interventions you trial / test. Human factors people or psychologists are a vital part of the team. They are only part of the team. You should see a pattern. What evidence (when it’s done and by whom) you collect, affects the intervention and its success. With no data you should not do any interventions. Indeed, without data you may not wish to. Remember it’s about outcomes and not just documented processes. In the words of the philosophers – Metallica – “nothing else matters”. Next time... Human factors part 2, or should we do interventions? Like the Star Wars films, these blogs may appear in the wrong order but the final box set hopefully makes sense! Comments welcome young Skywalker. Read Martin's other blogs Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4

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