Health Management and Policy Alert

Maternity and neonatal safety champions toolkit

NHS England -
This toolkit aims to provides information and resources to support safety champions to develop strong partnerships, promote positive professional cultures, and support the delivery of the safest care possible through best practice.

• Toolkit
• NHS England - publications

Never events: analysis of HSIB's national investigations

Healthcare Safety Investigation Branch (HSIB) -
‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening. This national learning report examines the findings of the investigations previously carried out by HSIB concerning incidents classified as 'never events'.

• Report
• Summary

MBRRACE-UK Perinatal Confidential Enquiry: stillbirths and neonatal deaths in twin pregnancies

MBRRACE-UK - 
This report represents the findings of the fourth perinatal confidential enquiry and focuses on stillbirths and neonatal deaths in twin pregnancies. This report contains illustrative vignettes which are taken from real life events. The vignettes are used to illustrate single aspects of care and are not intended to describe all the care provided to individual mothers and their babies.

• Report
• MBRRACE-UK - publications

Saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18

MBRRACE-UK -
This report examines the care received by women who die during or up to a year after pregnancy and covers all pregnancy-associated deaths involving UK women between 2016 and 2018. The results indicate that whilst maternal death is still rare in the UK, there are some important actions identified to prevent women from dying in the future.

• Report
• MBRRACE-UK - publications

Support for staff following patient safety incidents

Healthcare Safety Investigation Branch -
This report explores feedback from national investigators around positive efforts identified in the support of NHS staff by their organisations following patient safety incidents. It describes the literature around NHS staff support to attempt to identify areas of best practice and the impact of any interventions.

• Report
• Healthcare Safety Investigation Branch - publications

Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust

Department of Health and Social Care (DHSC) - 
This report outlines emerging findings and recommendations from an independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust which assesses the quality of investigations relating to newborn, infant and maternal harm at the trust. It makes system-wide suggestions and recommendations for action to improve maternity care.

• Report

Child sexual abuse in healthcare contexts

Independent Inquiry into Child Sexual Abuse -
This report finds that health care practitioners abused their positions of trust and authority to sexually abuse children under the guise of medical procedures. Based on the accounts of 109 victims and survivors who came forward to the Truth Project, the report analyses experiences of abuse across a wide range of health care settings from the 1960s to the 2000s. The report provides an insight into the role of health care in victims and survivors’ lives, revealing that for many participants, their health care needs related to the physical, psychological and sexual abuse they suffered at home.

• Report
• Independent Inquiry into Child Sexual Abuse - publications

The life and death of Elizabeth Dixon: a catalyst for change

Department of Health and Social Care - 

Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The independent investigation (chaired by Dr Bill Kirkup and commissioned by the Rt Hon Jeremy Hunt MP, as Secretary of State for Health) looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS.

• Report
• More detail

Delays to intrapartum intervention once fetal compromise is suspected

Healthcare Safety Investigation Branch -
This review aimed to dentify improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell. It was compiled after a review of 289 maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9 per cent of cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays.

• Report
• Healthcare Safety Investigation Branch - news

Out of sight – who cares?: a review of restraint, seclusion and segregation for autistic people, and people with a learning disability and/or mental health condition

Care Quality Commission -
This report tells the story of restrictive practices from the perspective of people who have experienced it first-hand and looks at how long-term segregation was used. The review finds that the environment of mental health hospitals was often not therapeutic. It also finds that some people were admitted without proper assessment and did not have an assessment of their needs while in hospital, resulting in the lack of a clear care and treatment plan.

• Report
• Care Quality Commission - publications