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Patient Safety Watch: All change for maternity transformation

Published on: 24 Feb 2023

HSJ is now hosting the Patient Safety Watch newsletter, written by Patient Safety Watch trustee James Titcombe.

Good afternoon and welcome to the Patient Safety Newsletter, brought to you fortnightly in collaboration with HSJ.

This fortnight’s edition includes the usual patient safety news roundup and an update on news with the maternity transformation programme, as well as sharing some good work happening across the NHS.

All set to change in maternity transformation

Several big changes are on the horizon for maternity safety. Earlier this month, Baroness Cumberlege announced she was stepping down from her role on NHS England’s Maternity Transformation Board and as chair of the Maternity Stakeholder Council. I’ve not always agreed with Baroness Cumberlege’s views, but everyone who has worked with her will agree that kindness and commitment to make a difference has been at the heart of everything she does. I wish her all the best as she steps down. No doubt her outstanding work in other areas, including pushing for action following the First Do No Harm report will continue.

Meanwhile, England’s chief nursing officer Ruth May has confirmed she is stepping in as interim chair of the Maternity Transformation Programme at the end of March. This is welcome news and will coincide with the anticipated launch of a new single delivery plan.

As every week passes, more news stories emerge pointing to problems for maternity safety; the task ahead should not be underestimated.

Last week, the Care Quality Commission imposed urgent conditions on East Kent Hospitals University Foundation Trust. The CQC identified a “number of concerns… primarily related to the safety of the labour ward environment, including the availability of regularly serviced equipment, processes for monitoring women and babies whose conditions deteriorate and risks of cross infection due to poor standards of cleanliness”.

East Kent has been part of the national Maternity Safety Support Programme – a programme of national support which is supposed to assure improvement – since December 2019. The most recent CQC action will rightly raise questions about the trust’s leadership, but perhaps we also need to be questioning what national support is given to trusts with known issues?

This week also saw the publication of a thematic review by the Healthcare Safety Investigation Branch, which looked at a number of maternal death and collapse events that occurred between January 2021 and May 2022 at the University Hospitals of Derby and Burton FT. HSIB said “robust action planning and prompt addressing of the learning” from previous recommendations from other investigations “may have had an impact on the outcome for the women who received care during the seven events included in the review”. The themes of the review are not dissimilar to other maternity safety inquiries and reports.

Next month will mark eight years since the Morecambe Bay Investigation report was published. From a personal perspective, I can’t help but reflect on the disappointment that similar issues to those identified by Bill Kirkup back in 2015 are still being raised today. Service users, maternity campaigners and maternity professionals will be watching closely as the new Maternity Transformation Programme is revealed in the weeks ahead. Change is welcome and overdue, but the question of whether it will be enough remains.

In other news…

Prescription costs leading to patients asking which they can ‘do without’

According to a survey by the Royal Pharmaceutical Society – and reported by The Guardian – more and more people in England are either not picking up their prescriptions or asking pharmacists which medicines they can “do without” because they cannot afford the £9.35 prescription charge. Chair of English pharmacy board of the RPS Thorrun Govind said: “We are deeply concerned that people are having to make choices about their health based on their ability to pay. No one should have to make choices about rationing their medicines and no one should be faced with a financial barrier to getting the medicines they need.”

Unlike in England, prescriptions are free in Scotland, Wales and Northern Ireland.

Doctors warn virtual ward plan will ‘put patient safety at risk’

The British Medical Association has raised concerns NHSE’s plans to create 10,000 “virtual ward” beds will put further strain on primary care. Kieran Sharrock, acting chair of the BMA’s England GP committee, told Pulse the plan relied on extra capacity being available elsewhere in the system, adding: “Virtual wards may solve the pressures problem in hospitals, but instead move them to another, equally-stretched part of the health service… Expecting GPs and their teams to support virtual wards without addressing the worsening workforce crisis will only drive up waiting times in general practice, and ultimately put patient safety at risk.”

As part of the move towards virtual wards – where patients who would have been admitted to hospital are monitored in community settings instead – 7,000 beds are already available with plans for an additional 3,000 beds, with hopes this can help treat up to 50,000 patients per month in a non-hospital setting.

NHS hospitals not caring for sickle cell disease patients properly, report finds

The Mirror has reported on research commissioned by the NHS Race and Health Observatory and carried out by Public Digital which has found sickle cell disease patients are receiving poor care in hospitals. In some cases, people put off seeking care for as long as possible, despite suffering terrible pain. The researchers found those with sickle cell disease – a group of inherited conditions which affect red blood cells and most commonly affect people from an African or Caribbean background – often felt their condition was undermined by healthcare professionals.

Independent review launched after ‘inexcusable behaviour’ exposed at mental health trust

Following BBC Panorama’s investigation into alleged mistreatment at Greater Manchester Mental Health FT’s Edenfield Centre, NHSE has ordered an independent review into the trust, as reported here by Manchester Evening News. The review, which is due to start this month and run until September, will examine the claims made in the broadcast but also concerns raised by patients, staff and their families. It will be led by Oliver Shanley.

When the trust’s chair Rupert Nichols stood down shortly after the programme was aired, he warned “inexcusable behaviour” and “unacceptable care” had been exposed at the trust’s medium-secure inpatient unit.

Healing After Healthcare Harm: A Call for Restorative Action

Earlier this month, the Harmed Patients Alliance (personal interest disclosed!) published a paper summarising the results of a survey to better understand how the response to an adverse event impacted on patients and families, and what they needed after they were harmed. The results make for stark reading and echo the themes of numerous other inquiries and reports. HPA is calling for action for all with a role in the aftermath of harm to take the causes of compounded harm seriously, and for the NHS to look to restorative principles and practices to inform more compassionate responses when things go wrong. HPA hope the paper will start a wider discussion about the changes needed across the healthcare system towards this aim.

Sharing some good stuff…

As I write these newsletters, I’m mindful a huge amount of good work is happening across the NHS aimed at making healthcare safer. Here are a few shares for this edition:

OptiBreech Trial issues safety alert

The OptiBreech Trial was set up to explore the feasibility of evaluating a new care pathway for women with a breech pregnancy. Shawn Walker, a consultant midwife and OptiBreech clinical lead and chief investigator, has produced an informative short video with information for women and maternity professionals about the risks associated with breech pregnancies and the combination of meconium and tachycardia, particularly in the first stage of labour. Great work and information that can only help women with a breech pregnancy make informed decisions.

New maternity governance board goes live at Tameside and Glossop

Staff at Tameside and Glossop Integrated Care FT have launched a new maternity governance board to “tell our story” and “understand where we are”. This looks like a great initiative – is this something other trusts might consider adopting?

Celebrating patient safety progress at Morecambe Bay

It was fantastic last week to see University Hospitals of Morecambe Bay FT celebrating patient safety progress with the trust’s first ever patient safety awards. The scheme is intended to encourage, celebrate and help spread quality of care and patient safety improvement across the trust. 

Just the job: A project to bring human factors into the healthcare workforce

In 2018, Steve Shorrock made a call to arms for healthcare organisations to wake up to the benefits of including human factors in healthcare. Lauren Morgan, who is an HF scientist in healthcare, has recently teamed up with Sue Deakin and David Higgins at West Suffolk FT to create a job description for a “human factors ergonomics specialist lead”. They hope the job description will be used as a template for other healthcare organisations.

I asked Lauren about the project. She said: “My involvement with WSH has come as they have brought human factors integration into their new hospital programme. It’s really great to see them embracing human factors to the full breadth of the science… it helps us design systems to support staff to do their best work, which now more than ever we need in the NHS”.

The job advert closes on February 28. The Clinical Human Factors Group has also published a sample job description template that can be adapted by trusts looking to recruit a human factors and ergonomics specialist.

That brings this busy edition to an end. Please look out for our next Patient Safety Newsletter in two weeks’ time.

Thanks for reading and stay safe.