Maternity pre-arrival instructions by 999 call handlers

Investigation summary

This national investigation explores factors influencing the instructions 999 call handlers give to women and pregnant people who have called 999 because of an emergency during their pregnancy and are waiting for an ambulance to arrive. These instructions are known as ‘pre-arrival instructions’.

Pre-arrival instructions are generated by a clinical decision support system (CDSS). There are two CDSS in use by ambulance services in England. One is an international system, and one is a UK-based system. Both systems have protocols for identifying the required response to urgent and emergency situations, including maternity issues.

Our national investigation was launched after similar concerns were identified in 15 HSIB maternity investigations. They all involved pre-arrival instructions generated by a CDSS. In each case the CDSS had generated pre-arrival instructions that had the potential to cause harm to the woman or pregnant person and/or their baby.

The reference event in this investigation involves Amy, who was 39 weeks and 4 days pregnant with her first child. She contacted 999 after experiencing abdominal cramps and bleeding.

While waiting for an ambulance to arrive, Amy received pre-arrival instructions which were generated through a clinical decision support system (CDSS) from a non-clinical call handler. Amy was then taken by ambulance to hospital where her baby, Benjamin, was delivered by emergency caesarean section.

Amy had excessive blood loss due to a placental abruption and was admitted to the high dependency unit for 12 hours following the birth. Benjamin required resuscitation to help him breathe on his own, he was intubated, and he received 72 hours of therapeutic cooling. He spent 13 days in hospital.

The investigation report is intended for healthcare organisations, policymakers and the public to help improve patient safety in relation to the instructions 999 call handlers give to women and pregnant people who are waiting for an ambulance because of an emergency during their pregnancy.

The investigation report:

Identifies the systemic factors influencing 999 call handler pre-arrival instructions.
Explores both the UK and international clinical decision support systems (CDSS) in relation to alignment and consistency of pre-arrival instructions with UK and international guidance.
Considers national regulation and governance mechanisms for CDSS content.

Safety recommendations

Department of Health and Social Care

HSIB recommends that the Department of Health and Social Care commissions the National Institute for Health and Care Excellence to work with relevant stakeholders to develop guidance for maternity emergencies in the non-visual, non-clinician-attended environment.

The Healthcare Safety Investigation Branch’s report recommended that the Department of Health and Social Care commissions the National Institute for Health and Care Excellence (NICE) to work with relevant stakeholders to develop guidance for maternity emergencies in the non-visual, non-clinician-attended environment.

The Department of Health and Social Care accepts this recommendation, subject to NICE’s initial scoping work. NICE will carry out some initial pre-scoping work with stakeholders to consider what outputs may be most helpful and what resourcing would be required for this recommendation.

Actions planned to deliver safety recommendation:

NICE to carry out initial pre-scoping work with stakeholders to consider what output may be most helpful, resourcing and timing by September 2022. Resources in place: Initial scoping work to be carried out within NICE’s existing budget.

Response received on 24 June 2022.

Department of Health and Social Care

HSIB recommends that the Department of Health and Social Care identifies a suitable regulatory mechanism to provide formal oversight of 999 maternity pre-arrival instructions across NHS-funded care in England.

The Healthcare Safety Investigation Branch’s National Report recommended that the Department of Health and Social Care identifies a suitable regulatory mechanism to provide formal oversight of 999 maternity pre-arrival instructions (PAIs) across NHS-funded care in England.

The Department of Health and Social Care accepts this recommendation.

The formulation of PAIs forms part of the clinical governance framework that is in place with the triage system provider; oversight of the clinical content rests with the triage system provider, and ambulance services are responsible for ensuring these PAIs are issued in response to appropriate remote triage. Following any NICE recommendations, NHSEI will ensure rollout of agreed consistent clinical guidelines.

Alongside its role in determining the priority category assigned to 999 calls, there is also a role for Emergency Call Prioritisation Advisory Group (ECPAG) in ensuring that developments and changes to PAIs are both suitable for the remote advice situation but also consistent with current guidance, including from NICE and the Royal Colleges.

ECPAG approved amendments to its Terms of Reference (ToR) to reflect the additional oversight required of PAIs going forwards. The ToR now include ECPAG putting in place a formal review process for the implementation and ongoing monitoring of the PAIs, following on from recommendations to PAIs being made and implemented. ECPAG will review information on any SIs or other concerns regarding maternity PAIs. Any suggested amendments will be taken forward through an agreed change process (to be determined through development of NICE guidance).

Actions planned to deliver safety recommendation:

ECPAG has formally accepted and amended its ToR to reflect the additional oversight required of PAIs going forwards. NHSEI will provide regulatory oversight through their involvement in the agreed process and will require ambulance trusts to adopt system updates. By: ASAP. Other dependencies identified: ECPAG will review information on any SIs or other concerns regarding maternity PAIs. Any suggested amendments will be taken forward through an agreed change process (to be determined through development of NICE guidance (as per HSIB rec R/2022/180). Additional comments: ECPAG will put in place a formal review process for the implementation and ongoing monitoring of the PAIs, following on from recommendations to PAIs being made and implemented.
Ambulance services will feed learning from service level reviews of incidents into the AACE Quality Improvement, Governance and Risk Directors (QIGARD). Where issues are identified, they will be escalated upwards for review and any actions incorporated into ambulance services systems.

Response received on 24 June 2022.

NHS England and NHS Improvement

HSIB recommends that NHS England and NHS Improvement develops the content of the patient safety incident investigation (PSII) standards to further support cross-boundary investigations.

We have reviewed our Patient Safety Incident Investigation (PSII) standards alongside all Patient Safety Incident Response Framework documentation. Our review included consideration of the recommendation raised by the HSIB in this report as well as feedback from our independent evaluation of our PSIRF early adopter programme. We have implemented the recommended change and look forward to publishing the revised documentation in June 2022.

Response received on 20 April 2022.

Maternity pre-arrival instructions by 999 call handlers

Jump to:

HSIB legacy content

Investigation summary

Safety recommendations

Department of Health and Social Care

Department of Health and Social Care

NHS England and NHS Improvement