More rigorous investigating needed to improve maternity safety

My Post (16)Coroners could be given powers to investigate stillbirths and help improve maternity safety, Health Secretary Jeremy Hunt has said. Currently, coroners only have jurisdiction to investigate deaths of babies who were alive at birth. The announcement comes after a recent report showed that three-quarters of birth-related deaths or brain injuries might have been avoided (Royal College of Obstetricians and Gynaecologists (RCOG), 2017).

Hunt also revealed that independent investigations are to be offered to families who suffer stillbirth or life-changing injuries to their babies. The Healthcare Safety Investigation Branch will look at 1000 cases each year to find out what went wrong and why, and encourage system improvements that will lead to fewer deaths and injuries in the future.

Health Secretary Jeremy Hunt said:

‘The tragic death or life-changing injury of a baby is something no parent should have to bear, but one thing that can help […] is getting honest answers quickly from an independent investigator. Too many families have been denied this in the past, adding unnecessarily to the pain of their loss.

‘Countless mothers and fathers who have suffered like this say that the most important outcome for them is making sure lessons are learnt so that no-one else has to endure the same heartbreak. These important changes will help us to make that promise in the future.’

Alongside the devastating impact of death or serious injury to mother or child at birth, maternity incidents dominate the NHS’ litigation expenditure. Half of the £1 billion negligence claims the NHS paid out in 2016/17 were in maternity services, largely due to the high value of claims arising from brain injuries at birth (NHS Resolution, 2017).

The Government’s maternity safety plans will also see its ambition to halve the number of stillbirths and deaths among neonates and mothers brought forward from 2030 to 2025 (Department of Health, 2017), saving an estimated 4000 lives.

The rate of premature births is also hoped to fall from 8% to 6% by 2025.

Gill Walton, chief executive officer and general secretary at the Royal College of Midwives (RCM), said:

‘Midwives are in a unique position to help achieve this, as they are the one healthcare professional whom all women will see during their pregnancy and birth, and therefore have a clear role in ensuring care is coordinated, safe and, most importantly, personal.

‘Much has been done already through an array of initiatives to improve the safety of maternity care, and this revised strategy will give everyone involved in maternity care the opportunity to reflect on past successes and focus on key areas where more still needs to be done.’

The RCOG ‘Each Baby Counts’ programme has used local investigations into stillbirths, neonatal deaths and brain injuries to inform national data and identify lessons learned across maternity services. One-quarter of local reports were deemed inadequate by the RCOG, with many NHS institutions listed as not sufficiently investigating incidents and learning from mistakes in their maternity services.

Commenting on the proposals, Professor Lesley Regan, RCOG president, added:

‘We are delighted that the Government has agreed to expand the RCOG’s Each Baby Counts programme, which has been hugely successful in securing the trust of both the midwifery and obstetric communities, with 100% of Trusts involved in providing maternity services engaging in this important work.

‘We are committed to sharing the expertise we have gained […] and our understanding of the complex interplay of factors that lead to stillbirths, neonatal deaths and brain damage during term labour, to work with partners such as NHS Improvement to expand the work and reach of the Maternal and Neonatal Safety Collaborative and the Healthcare Safety Investigation Branch as they undertake their investigations.

‘Expansion of the national strategy to include a focus on preterm birth and brain injury will likewise help provide a more complete picture of maternity safety, strengthening our evidence base to help us deliver ever more effective care’.

References

Department of Health. Safer Maternity Care: The National Maternity Safety Strategy— Progress and Next Steps. London: The Stationery Office; 2017

NHS Resolution. Annual report and accounts 2016/17. London: The Stationery Office; 2017

Royal College of Obstetricians and Gynaecologists. Each Baby Counts: 2015 Summary Report. London: RCOG; 2017

Taken from British Journal of Midwifery, published February 2018.

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Not enough ‘safe care’ for maternity service users, warns NHS England

Adobe Spark (8)The chair of the Maternity Transformation Programme in England has warned that not enough is being done to ensure safety within maternity services. Speaking at the NHS England Health and Care Innovation Expo, Professor Sarah-Jane Marsh, said:

‘There are too many families […] who have not had safe care, who we have let down, and we need to do better.

‘Safety has to be at the heart of everything that we do in our maternity services. We have got to get it right. We know how to get it right, [but] often we just don’t do that consistently.’

In Better Births (NHS England, 2016), NHS England emphasised the need for safer, personalised, professional, family-friendly maternity services, realised through Local Maternity Systems, the maternity element of Sustainability and Transformation Plans (STPs). Here, providers, commissioners and organisations work at a local level to oversee and develop health care issues.

While Marsh called the vision ‘clear’, she cautioned that it was not ‘what is being talked about in every maternity unit in the country at the moment.’

Since the Maternity Transformation Programme was launched in July, 44 Local Maternity Systems have been set up to plan the design and delivery of services to populations of 500 000–1 500 000 people. Marsh claimed that these are making headway, and are looking towards the future of maternity services ‘with a ruthless focus on safety and personalisation.’ Although services are becoming safer, she warns that performance, when benchmarked against maternity staff, ‘is not as it should be’.

Marsh also raised concerns that boards are not as focused on maternity services, saying:

‘We need to have people, at board level, who really understand maternity safety, who understand how to get it right as well as to investigate when things go wrong.’

Marsh stressed that, while visions and national programmes are important,

‘The change that really matters is that which is made by clinical teams on the ground, coming together to want to make a difference for the patients, the families, the women they care for. And the women and families themselves having every opportunity to be able to participate, feedback their experience and work with professionals to improve services.’

Marsh also highlighted the importance of multiprofessional working, saying,

‘We need to see ourselves as one big maternity team […] We have got to move away from the idea that maternity care is purely about the midwives and the obstetricians, because there is so much more to it than that. […] Those who work together and train together ultimately go on to do even more personal and safe care.’

This sentiment was also emphasised by Professor Jacqueline Dunkley-Bent, head of maternity, children and young people for NHS England, who said:

‘We are working really hard and we will continue to work hard to ensure that avoidable death is reduced in this country. We have a commitment at the moment on the table from the Department of Health: £8 million has been allocated to support education and training. This fund has been awarded to maternity services to help them develop multidisciplinary training.’

Matthew Tagney, director of the Maternity Transformation Programme, agreed that progress was being made, but warned that the NHS was still far from its target of halving stillbirths, maternal and neonatal deaths, and brain injuries during or soon after birth by 2030:

‘I think there is a tremendous amount happening both nationally and locally.We are on track for 2020 but there is a huge amount more to do.’

While progress is being made on the delivery of better maternity services, there is still a long way to go. This was accepted by Marsh, who apologised to the hundreds of families who had lost babies:

‘You have my commitment and the commitment from the team at NHS England that we will work tirelessly every day to do the things that we know work in patient safety, and to make sure there are no baby deaths in this country that are avoidable.’

References

NHS England. National Maternity Review: Better Births—Improving outcomes of maternity services in England—A Five Year Forward View for maternity care. Leeds, NHS England: 2016

Taken from British Journal of Midwifery, published November 2017.