NHS England and NHS Improvement
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 (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"We do not publish national clinical guidance, but we will work with key stakeholders to further help align clinical guidance and improve consistency and clarity.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.
NHS England and NHS Improvement
HSIB recommends that NHS England and NHS Improvement leads work to collate and act on the evidence on the risks and benefits associated with the use of remote consultations at critical points in the maternity care pathway.
Action: The NHSE/I MTP Insight Oversight Group will ascertain what evidence/work is underway looking at remote consultations. By: April 2022. NHSE/I Insight Oversight Group, with Royal Colleges and THIS Institute.
Action: The NHSE/I MTP Insight Oversight Group will collate evidence on the risks and benefits of remote consultations and share with the relevant organisations (RCOG/RCM/NICE) to help inform their future guidance on remote consultations. By: June 2022. NHSE/I Insight Oversight Group. Working with Royal Colleges and NICE.
Response received on 14 December 2021.
NHS England and NHS Improvement
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.
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.
NHS England and NHS Improvement
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.
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.
NHS England and NHS Improvement
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.
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.
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.
"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.
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 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.
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 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.