Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020 — HSSIB Investigation

Summary

7 recommendations 3 observations 6 learning prompts 7 of 7 responded

Safety Recommendations

7 total

R/2021/146 NHS England

HSIB recommends that NHS England and NHS Improvement leads work to develop a process to ensure consistency and clarity across national maternity clinical guidance.

NHS England and NHS Improvement committed to working with stakeholders to align clinical guidance. They will develop a national registry of recommendations by June 2022 and use an oversight group to improve consistency and clarity by August 2022.

Response received 14 December 2021

"NHS England and NHS Improvement (NHSE/I) welcome this report and will work closely with relevant stakeholders to consider how best to implement the recommendations. "We do not publish national clinical guidance, but we will work with key stakeholders to further help align clinical guidance and improve consistency and clarity. "We will ascertain and collate evidence around the risks and benefits of remote consultations and share with the relevant organisations to help inform the development of future guidance on remote consultations. "In reference to safety recommendation R/2021/146, the Royal College of Obstetricians and Gynaecologists (RCOG) are currently considering a best practice guide for maternity triage. In the meantime, we will review and describe best practice in telephone triage and work with local maternity systems to develop recommended minimum operating standards for pre-assessment maternity telephone triage services. "We will review national guidance for interpretation services for maternity users and work with NHS Shared Business Services (SBS) to incorporate into the procurement framework a minimum operating standard for interpretation services in maternity care which will include a communication risk assessment. "In collaboration with national maternity partner organisations, we have developed ‘The Core Competency Framework’, which contains neonatal life support as a core module. We will review the minimum requirements for this module to include the need for Trusts to develop their own local framework to identify and mitigate potential risks in relation to neonatal resuscitation." Action: NHSE/I Maternity Transformation Programme (MTP) Insight Oversight Group will develop a ‘live’ national registry of published recommendations to help ensure consistency across national maternity clinical guidance. By: June 2022. Action: NHSE/I will use the MTP Insight Oversight group, including representatives from RCOG, RCM and NICE, to further help align clinical guidance and improve consistency and clarity. By: August 2022. NHSE/I Insight Oversight Group, working with RCOG, RCM, NICE. Response received on 14 December 2021.

R/2021/149 NHS England

HSIB recommends that NHS England and NHS Improvement leads the development of minimum operating standards for pre assessment maternity telephone triage services to support safe and consistent telephone triage to ensure reliable identification of risks.

NHS England and Improvement commits to reviewing best practice and developing recommended minimum operating standards for pre-assessment maternity telephone triage services by June 2022. A general maternity triage guide is in approval, but does not cover telephone triage.

Response received 14 December 2021

Action: NHSE/I will review and describe best practice in telephone triage and work with local maternity systems to develop recommended minimum operating standards for pre-assessment maternity telephone triage services. By: June 2022. NHSE/I Infrastructure Oversight Group, working with RCOG. A Best Practice Guide on Maternity Triage has been developed and is currently going through the approval process at the Royal College of Obstetricians and Gynaecologists. This does not currently cover telephone triage. Response received on 14 December 2021.

R/2021/150 NHS England

HSIB recommends that NHS England and NHS Improvement develop minimum operating standards for interpretation services in maternity care which will include a communication risk assessment.

NHS England and Improvement commits to reviewing national guidance and incorporating minimum operating standards for maternity interpretation services, including a communication risk assessment, into the procurement framework by June 2022.

Response received 14 December 2021

Action: NHSE/I will review national guidance for interpretation services for maternity users and work with NHS Shared Business Services (SBS) to incorporate into the procurement framework a minimum operating standard for interpretation services in maternity care which will include a communication risk assessment. By: June 2022. MTP [Maternity Transformation Programme] – Safety Improvement Team. NHS Shared Business Services (SBS). Resources in place: NHSE/I MTP with NHS Shared Business Services (SBS). Interpretation and Translation Services - NHS SBS. Response received on 14 December 2021.

R/2021/151 NHS England

HSIB recommends that NHS England and NHS Improvement develop a framework to support Trusts to anticipate operational risk in maternity services when delivering neonatal resuscitation.

NHS England and Improvement will review their existing National Maternity Core Competency Framework by June 2022. This review will ensure it includes the requirement for Trusts to develop local frameworks to identify and mitigate operational risks during neonatal resuscitation.

Response received 14 December 2021

Action: NHSE/I’s National Maternity Core Competency Framework contains minimum standards in relation to neonatal life support. By: in place. NHSE/I. Resources in place: Training resources in existing maternity baseline funding. Action: NHSE/I will review the minimum requirements for this module to include the need for Trusts to develop their own local framework to identify and mitigate potential risks for maternity and neonatal services when responding to the need for neonatal resuscitation. By: June 2022. Response received on 14 December 2021.

R/2021/145 Royal College of Obstetricians and Gynaecologists

HSIB recommends that future iterations of the Royal College of Obstetricians and Gynaecologists’ guidance clarify the management of a reported change in fetal movements during the third trimester of pregnancy with due regard to national policy.

The RCOG confirmed their Green Top Guidance on Reduced Fetal Movement is independently undergoing an update. They anticipate the new guidance, clarifying fetal movement management, will be available by late 2022 or early 2023 after standard review processes.

Response received 14 December 2021

"Thank you for sharing this safety recommendation that relates to the Green Top Guidance on Reduced Fetal movements (RFM), published in 2011. The report identifies differences between that guidance and subsequent guidance published outside the RCOG by NHS England in 2019. "The report does not refer to any data that links these differences in guidance with intrapartum stillbirth during the Covid pandemic and nor are there any data to indicate a direct relationship between a history of RFM and intrapartum stillbirth. Finally, both guidelines predate the Covid pandemic. "Independently of the report, the RCOG Green Top Guidance on Reduced Fetal movement is currently being updated with any evidence that meets our standards for inclusion. We anticipate the new guidance will be available end of 2022 early 2023 after our standard peer review and revisions." Action: GTG 57 review in early 2023 by the Guidelines Committee. Response received on 14 December 2021.

R/2021/147 NHSX

HSIB recommends that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record, and also support alerting functionality.

NHSX is working to accelerate the deployment of maternity electronic patient record (EPR) systems. They are ensuring these systems communicate with one another and include functionality for both patients and professionals to add to the record.

Response received 26 November 2021

"NHSX is working with the NHS England and NHS Improvement Transformation Board to accelerate the deployment of electronic records systems to support maternity care and also to ensure that, with appropriate security and permissions, these systems communicate with one another (between trusts, organisations and geographical boundaries) and offer a digital window to women, pregnant people and their families. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record." Response received on 26 November 2021.

R/2021/148 Department of Health and Social Care

HSIB recommends that the Department of Health and Social Care commission a review to improve the reliability of existing assessment tools for fetal growth and fetal heart rate to minimise the risk for babies.

The Department of Health and Social Care accepts the recommendation and plans to commission research to improve fetal growth and heart rate assessment tools. They will submit a proposal for this research in early 2022, subject to necessary approvals.

Response received 3 December 2021

"The Healthcare Safety Investigation Branch’s National Learning Report recommended that the Department of Health and Social Care commissions a review to improve the reliability of existing assessment tools for fetal growth and fetal heart rate to minimise the risk for babies. "The Department of Health and Social Care accepts this recommendation. Subject to the necessary approvals, we will look to commission this research in due course." Action: Seek approvals to commission research. Timeline: Submit proposal early 2022. Lead: DHSC. This is the earliest possible intake for Research and Development proposals. Response received on 3 December 2021.

Safety Observations

3 total

Observation 1 Observation It may be beneficial if further work is done to understand the specific aspects of the healthcare system which could explain the disparity in the experience and risk for women and pregnant people from Black, Asian and minority ethnic backgrounds and those with higher socio-economic deprivation.

Observation 2 Observation It may be beneficial if multidisciplinary simulation is considered as a tool to support prospective risk analysis for neonatal resuscitation.

Observation 3 Observation It may be beneficial if expertise applied within other safety critical industries is integrated into the development and implementation of a maternity-focused proactive safety management system.

Learning Prompts

6 total

Prompt 1 Learning prompt Guidance In response to the changing situation and developing understanding of risks during the first wave of the COVID-19 pandemic, a large volume of rapidly changing guidance was produced. Despite best efforts to make this accessible to staff, investigations found variation in local implementation, difficulty in assimilating the changes and in one instance an important discrepancy between two sets of current national guidance on the management of reduced fetal movements.

Prompt 2 Learning prompt Management of risk Although the NHS identified continued provision of maternity services as a priority, operational changes were made to reflect the need to reduce the risk of transmission of infection. In all the cases reviewed, the women and pregnant people received the recommended number of appointments and scans, and appropriate bereavement care was provided. Some face-to-face antenatal (pre-birth) visits were replaced with remote consultations, resulting in fewer opportunities to perform physical examinations such as symphysis-fundal height measurement (measurement of the size of the uterus which is used to assess a baby’s growth during pregnancy), and carbon monoxide testing (a simple non– invasive breath test which gives women an immediate indication of the carbon monoxide level in their body) was paused. Some hospital ultrasound scans were stopped or delayed during this period.

Prompt 3 Learning prompt Telephone triage Difficulties in communication were identified, relating to the availability and presentation of clinical records, documentation and communication of information from triage calls, and availability of interpretors particularly in urgent circumstances. The usual reliance on family members to provide translation support, which is not in line with national guidance, was emphasised when policies were introduced requiring women and pregnant people to attend antenatal appointments alone.

Prompt 4 Learning prompt Interpretation services The review identified that family members do provide translation support when interpretation services cannot be provided by the local maternity service, even though this is not in line with national guidance. However, during the first wave of the pandemic, when women and pregnant people were required to attend antenatal appointments alone, the provision of interpretation services was even more critical.

Prompt 5 Learning prompt Work demands and capacity to respond Changes were identified in work processes, staffing levels and physical layout of the space in which staff were working, resulting from the pandemic. Membrane sweeps (a midwife or doctor uses a single finger to sweep around the cervix), designed to reduce the need for formal induction of labour, were stopped in some centres, to reduce the infection risk associated with more prolonged contact between patients and staff. Some of the necessary changes made to the physical space, for example to enable staff to don and doff (put on and take off) personal protective equipment, had unintended and unforeseen consequences in terms of the usability of equipment in its new position.

Prompt 6 Learning prompt Neonatal resuscitation The review highlighted gaps between how neonatal resuscitation (delivery of inflation breaths with or without chest compressions) is expected or imagined to work and how it actually happens. This issue has been highlighted in other types of national reports. The review identified that existing systems, equipment and environments to support neonatal resuscitation do not appear to consistently enable all staff to act and respond as required by the guidance.