During the coronavirus peak
During this time, we minimised our impact on the healthcare system and we did not take part in any non-COVID related national investigations.
We reviewed and adjusted the reporting criteria for maternity investigations, continuing to undertake interviews using telephone or video conferencing facilities.
We also enabled and supported many of our own staff to return to the frontline including intensive care units, general medical wards, COVID-19 wards and maternity units.
Current situation (July 2020 onwards)
Like many organisations we have been following government guidance through the COVID-19 pandemic, and we have now begun to restart our national investigations programme. We are doing this slowly and following our own COVID-19 safety protocols as well as those required by any hospital or healthcare organisation we visit.
Face-to-face interviews are only taking place in exceptional circumstances, with our preference being to conduct tele or video conferencing. At times our in-depth investigations require critical visual observations and site visits to collect the information required.
Family and patient visits for both the maternity and national programmes are done remotely where possible, and we conduct risk assessments for any visit to ensure the safety of patients, families, trust staff and of our own HSIB employees.
Our first national learning report since the start of the pandemic was published on 16 July 2020 - ‘Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection’. Over the coming months more national learning, national intelligence and national investigation reports will be published.
Since the beginning of the pandemic we have collated and analysed safety intelligence from issues arising during the COVID-19 crisis. This is forming the basis for some of our work programme over the next 6 to 12 months to help the service prepare for future safety challenges.
We will remain vigilant of the lifecycle of the coronavirus pandemic and will ensure we follow government guidelines at all times.
National investigations (March to July 2020)
We worked tirelessly to support the healthcare system’s response to the COVID-19 outbreak, assisting with the development of the NHS Nightingale hospitals, whilst also aiding trusts across the country in areas where our investigatory expertise was considered essential.
For example, we helped improve safety in oxygen supply systems at trusts and improved efficiency and safety at local, mobile and fixed coronavirus testing facilities for keyworkers and the public.
At the Nightingale sites our investigators took part in site visits and provided advice to field hospital managers and clinicians to improve the working environment and layout of essential patient equipment to reduce the potential for patient safety errors.
We also provided advice on infection control, and to help troubleshoot problem areas associated with the swift erection of temporary healthcare facilities.
In addition, we developed Rapid Response Teams to react within hours of a patient safety notification.
Maternity investigations (March to July 2020)
Our maternity investigations continued throughout this time.
We adapted our investigation criteria and no longer routinely investigated maternity events involving cooled babies where there was no apparent neurological injury confirmed following therapy. Cooling therapy is a process of cooling and gradually re-warming a newborn baby who has experienced oxygen deprivation. It improves neurodevelopmental outcome in survivors.
Our investigation team has continued to investigate maternal deaths, neonatal deaths and babies who have required cooling with an abnormal brain scan. We have also continued to investigate cooled babies with normal brain scans if the families have concerns regarding their care.
The maternity team has worked with MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) to provide detailed information related to the COVID-19 impact on maternal deaths in England and have collaborated on the upcoming report, due to be published in August 2020.
The teams have worked to develop new processes and ways of engaging with trusts, staff, and families to ensure investigations have been completed.
Family feedback remains positive during the pandemic.