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Healthcare Safety Investigation Branch release their independent report on delays in intrapartum intervention

Approximately 650,000 babies are born each year in England and Wales (Office for National Statistics, 2019); the vast majority are delivered safely. However, England and Wales have higher numbers of babies who are stillborn and neonatal deaths compared to other high-income countries.

Background to the HSIB Report

In 2014 the Royal College of Obstetricians and Gynaecologists launched Each Baby Counts a national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. From 1 April 2018, the Healthcare Safety Investigation Branch (HSIB) have been responsible for all NHS patient safety investigations of maternity incidents which meet criteria for the Each Baby Counts programme and also maternal deaths (excluding suicide).

In October 2017, the Each Baby Counts programme published findings relating to the care of babies born during 2015.  0.1% of babies born in 2015 fulfilled the Each Baby County criteria and were deemed to have sufficient information to make a judgement about the quality of care. It was concluded that of this 0.1% different care may have led to a different outcome in 76% of those cases.

The Each Baby Counts reviewers identified that ‘human factors’ were a contributory factor in 53% of cases where different care may have led to a different outcome. The most frequent ‘human factor’ identified was lack of ‘situational awareness’. Other factors included stress and fatigue.

Fetal monitoring was also identified as a critical contributory factor in 74% of cases. The equipment used for fetal monitoring is the subject of a separate HSIB investigation.

The Report: Delays in intrapartum intervention once fetal compromise is suspected

The Report published today, 12 November 2020, focuses on HSIB’s investigation and recommendations in relation to the ‘human factors’ which were found to be a contributory factor in the cases where different care may have led to a different outcome.

The findings of the HSIB report were that there is a recurring theme in many investigations into maternity services of issues with ‘situational awareness’ being a contributing factor. This has often been characterised as something which is within the individuals control and that as such could be improved with further training. However, HSIB identified that ‘situational awareness’ is actually an organisational issue involving interaction between staff and the whole working system. In coming to their safety recommendation, they identified the fact that labour ward co-ordinators are often unable to monitor performance and anticipate possible issues effectively due to other work demands. They therefore proposed a second person to oversee the maternity services. They identified a need for regular multidisciplinary ward rounds and for in situ simulation training. They also identified need for providing clinical review at triage stage and physical changes such as relocating Consultant’s offices nearer to the labour ward. They also identified a need to increased teamwork and psychological safety for staff working in maternity units.

Following the investigation, HSIB has made the following Safety recommendation (R/2020/103):

“It is recommended that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary teamwork and psychological safety in its regulation of maternity units.”

The full HSIB report can be found here.

It is hoped that implementing the recommendations of the HSIB report will further improve patient safety in maternity services.

In the event that you have concerns about maternity services you have received and would like some further advice, please contact a member of our experienced team who would be happy to discuss your concerns.


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