Lack of Shared Understanding a Safety Risk in NHS Maternity Units

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Inadequate staffing, excessive workloads and poor infrastructure are leading to NHS maternity staff delaying critical interventions during birth. This is the view of the Healthcare Safety Investigation Branch (HSIB), which said these delays are a “recognised patient safety risk”.

But the HSIB believes NHS maternity services could make improvements by encouraging a shared understanding of what’s happening across their department, so staff can effectively monitor performance and anticipate what’s needed in the future.

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Recurring Problems in NHS Maternity Services

The HSIB reviewed numerous recent reports on improving patient safety at NHS maternity units and found several common themes. For instance, some highlighted a lack of awareness and understanding by staff of what’s going on around them.

But the HSIB argued that awareness of a situation should be an “organisational issue”, rather than something that’s under an individual’s control. So it’s suggested that a new role be created to solve this problem. This person would focus on monitoring activity across the maternity unit and anticipate future events, rather than provide hands-on care themselves.

The HSIB said shared understanding of a situation could be encouraged in many ways, such as safety huddles and by using structured information sharing tools.

The report also noted that high workloads and inadequate staffing are causing problems in NHS maternity services, but suggested that encouraging a sense of teamwork and promoting “psychological safety” could make performance more resilient.

The HSIB has recommended that the Care Quality Commission work with other stakeholders to change how it regulates maternity units, so it also looks at factors such as psychological safety and multi-disciplinary teamwork.

Finally, poor physical infrastructure in NHS hospitals was identified as an issue that affects patient safety in maternity units.

The HSIB acknowledged that changing some aspects of a healthcare setting’s physical layout is difficult, but said some changes could still be made to make them more resilient. For example, consultant offices could be placed on or near the labour ward, while there could be greater use of digital cordless telephones.

The HSIB compiled the report after reviewing 289 previous maternity investigations into stillbirths, neonatal deaths and potential severe brain injuries. Delays to critical interventions contributed to these outcomes in nearly 15% of the cases they looked at.

Dr Louise Page, Maternity Clinical Advisor at HSIB said, “At a time when there is unprecedented pressure on maternity services across the NHS, we hope this report will aid Trusts and contribute to the shared goal of improving safety for mothers and babies across the country.”

We agree, as it’s vital that processes are put in place to share best practice both within teams and across different NHS Trusts, and lead to consistently high standards across the board.

The role of staff in achieving this can’t be understated, as they must be armed with the right knowledge and able to follow processes that encourage effective care and patient safety.

We understand that in a busy NHS maternity unit, the demands on staff can change at a moment’s notice. But it’s clear that changing demands shouldn’t lead to patient safety being compromised, as the consequences can be devastating for all involved.

If you have any concerns about the care you received at an NHS maternity unit, contact our expert Medical Negligence Lawyers.

We offer a free claims assessment and will be happy to discuss your situation with you and how we can help you. We could deal with your claim on a No Win, No Fee basis - ask us for details.

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