The review was prompted by an increase in referrals of intrapartum stillbirths we received, that fitted specific criteria between April and June 2020 (45 compared to 24 in the same period in 2019).
We then thematically analysed 37 maternity investigation reports focused on intrapartum stillbirths, from the April to June time period to understand what learning could be drawn from these cases. While none of the women and pregnant people were recorded in HSIB maternity reports as having the virus, the national report describes how the pressures and changes as a result of the pandemic may have impacted on the care they received.
Findings in the report suggest that many safety risks that were identified in the review were already known to maternity services and these were further exacerbated by the pandemic, for example, the sustainability of staffing levels in maternity units. It also highlighted that COVID-19 created specific safety risks including the impact of limiting face to face interactions and increasing remote consultations.
The findings have been summarised into six key themes:
- Guidance - findings in maternity investigation reports emphasised the challenges in interpreting and ensuring the consistent implementation of rapidly changing national guidance in relation to COVID-19.
- Management of risk – this theme covered how Trusts balanced emerging and uncertain risks of COVID-19 with known existing risks associated with pregnancy and the impact of operational changes e.g. the move to remote consultations.
- 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 interpreters particularly in urgent circumstances.
- Interpretation services – the review highlighted that 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.
- Work demands and capacity to respond – recognised challenges in ensuring consistency and availability of appropriate clinicians within maternity services were exacerbated due to the response to the COVID-19 pandemic and increased levels of staff sickness and absence.
- Neonatal resuscitation (resuscitation of the newborn baby) – this theme highlights the variability in the timing and efficiency of neonatal resuscitation and suggests a need for Trusts to proactively manage predictable risks.
The report concludes with eight safety recommendations and three safety observations aimed at reducing variation and improve safety regarding the development of maternity guidance, remote consultation, communication, monitoring of fetal wellbeing, telephone triage, and availability of interpretation services. Further safety recommendations relate to taking a proactive approach to the assessment of patient safety risks and the use of an overall safety management system in maternity care, as used in other safety-critical industries.
Kathryn Whitehill, Principal National Investigator at HSIB says: “ We recognise that the current maternity system has had success through national initiatives in reducing the number of stillbirths and that throughout the pandemic, thousands of babies were delivered without any problems. However, our review did highlight the extreme pressure maternity services were under – they had to balance the risks associated with uncertainty and emerging evidence on COVID-19 transmission with the clinical assessments that are needed to monitor the safety of patients. We also felt it was crucial to reflect the experience of women and pregnant people to emphasise how the changes to services affected them and their families.
“As the NHS continues to tackle COVID-19 and deal with the impact on services, it is important that learning is shared across the system. Our review provides an independent examination of the factors that influenced care during the first wave. Our recommendations are aimed at identifying where there might be gaps in safety management and supporting the system to take a proactive approach in ensuring the wellbeing and effective care of women and pregnant people and their babies across the country.”
- NHS England and NHS Improvement leads work to develop a process to ensure consistency and clarity across national maternity clinical guidance.
- 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.
- 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.
- 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.
- 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.
- 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 NHS Improvement develop minimum operating standards for interpretation services in maternity care which will include a communication risk assessment.
- NHS England and NHS Improvement develop a framework to support Trusts to anticipate operational risk in maternity services when delivering neonatal resuscitation