A pregnant woman with short blonde hair stands in her living room with one hand on her bump, while making a phone call.

New report explores safety risks associated with maternity pre-arrival instructions by 999 call handlers

by Communications team

Our latest report highlights that maternity pre-arrival instructions from 999 call handlers could represent a ‘postcode lottery’ of care for women and pregnant people experiencing maternity emergencies.

The national investigation was launched after a safety risk was identified in 15 of our maternity investigations where those calling 999 were given pre-determined instructions that did not match aspects of UK evidence-based maternity guidance that would be used by clinicians in a clinical setting.

Reference case

To illustrate the potential patient safety issues, the investigation examined the reference case which focused on Amy, a 30 year old woman in her first pregnancy.

She was at home on her own and called 999 as she was experiencing abdominal pain and vaginal bleeding. During the call, she was told to collect items that she would need if she gave birth. She was also advised to lie on her back in the centre of the bed or on the floor and to raise her head with pillows until the ambulance arrived.

Her baby, Benjamin, was born in the hospital via emergency caesarean. At birth, he required resuscitation and received 72 hours of therapeutic cooling. It was confirmed after the birth that the placenta had come away from Amy’s uterus prematurely; this was the cause of her pain and bleeding.

Key findings

The wider investigation reviewed the context and contributory factors influencing the pre-arrival instructions given. A key finding set out in the report is that 999 call handlers across England use one of two endorsed pre-arrival triage systems, which provide different instructions/advice to women/pregnant people with differing clinical implications, for the same maternity emergencies. In Amy’s case, the advice to lie on her back whilst awaiting ambulance arrival was in conflict with maternity clinical guidance for clinicians. This advice had associated risks which had the potential to have contributed to the outcome for Benjamin.

As well as highlighting the inconsistency between the triage systems, we also emphasise that there are gaps in governance and regulation. We identified that there is a gap in maternity emergency guidance for advice that is given over the phone (non-visual) during a maternity emergency, when there is no healthcare professional with the patient (non-clinician attended). We also found that local hospital investigations into poor outcomes for mothers and babies would not routinely consider other recent aspects of pre-hospital care.

The report concludes with three safety recommendations focused on development of guidance for the non-visual, non-clinician attended environment, implementing formal oversight for pre-arrival instructions and providing further support to undertake cross-boundary patient safety investigations.

Craig Hadley cut.jpg
Craig Hadley, HSIB National Investigator

Investigator's view

Craig Hadley, National Investigator at HSIB, says: “Our investigation highlighted where there might be inconsistency and conflict between systems and the challenges when maternity advice in pre-hospital situations is given by non-clinicians to women/pregnant people who are potentially at home on their own.

“The aim of the investigation and the resulting safety recommendations is that experts in maternity care and pre-hospital emergency triage can develop appropriate maternity guidance for this specialist environment. This will reduce inconsistency and the current postcode lottery situation, providing safe telephone triage and advice to women/pregnant people across England.”

Read the report

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