Story Highlight
– NHS introduces new standards to reduce maternal deaths.
– Sandwell trust to review all stillbirths from 2025.
– NHSE considers home birth service withdrawal guidance.
– Safety concerns over nurses filling doctor rota gaps.
– Campaign calls for safer medical cannabis prescribing.
Full Story
**Patient Safety Watch: Recent Developments in Maternity Care and Hospital Safety**
The latest edition of the Patient Safety Watch newsletter brings significant developments in the field of maternity care and critical insights into patient safety across hospitals in the UK. This fortnight’s focus highlights crucial updates aimed at enhancing maternal healthcare, addressing ongoing concerns within trusts, and examining the implications of recent proposals by NHS England.
**New Standards Aim to Mitigate Maternal Mortality**
NHS England has introduced a comprehensive set of clinical standards intended to decrease the rate of maternal deaths. These standards emphasise early detection of risk factors and improved access to specialist care, concentrating on prevalent causes of maternal mortality, such as sepsis, haemorrhage, strokes, blood clots, pre-eclampsia, cardiac conditions, and mental health issues including suicide.
As part of these measures, all pregnant individuals will undergo an early assessment for venous thromboembolism. Those identified as high-risk will receive preventative care within a 72-hour window. Furthermore, women suffering from epilepsy will be connected to dedicated specialist teams to create personalised care plans. The standardisation of mental health evaluations and clearer pathways for referrals are aimed at expediting senior clinical involvement, particularly in cases of haemorrhage.
This announcement coincides with the rollout of the Maternal Outcomes Signal System (MOSS), a new initiative designed to identify emerging safety concerns in maternity settings. Developed in response to findings from the East Kent report, this system aims to enhance monitoring and accountability.
Kate Brintworth, the Chief Midwifery Officer for England, stated, “We still see symptoms of serious medical problems being missed, especially for Black and Asian women. By setting out these clinical standards and holding hospitals to account, we can significantly reduce avoidable deaths and prevent future tragedies.”
**Sandwell Trust to Review Stillbirth Cases Amid Inspections**
In a significant move, Sandwell and West Birmingham Trust has decided to reassess all stillbirth cases dating back to 2025. This review will scrutinise the quality of care provided as well as the internal investigations facilitated by the national perinatal mortality review tool (PMRT).
Concerns regarding the trust’s PMRT process surfaced after an inspection by the Care Quality Commission (CQC) earlier this year. The CQC found that in a sample of 19 stillbirth cases, none were identified as having care issues that could have affected the outcomes, despite indications of diagnostic errors, monitoring lapses, and inadequate communication.
Family members impacted by these tragic events have expressed frustrations about the lack of transparency and meaningful involvement in these investigations. Tom Hender, whose son Aubrey was stillborn at the trust, remarked that PMRT reviews represent the “only form of investigation open to many parents,” and suggested that the CQC’s findings may indicate deficiencies in the investigative process. He further questioned why the review only extends to cases from 2025.
This comprehensive review is expected to conclude by the end of July.
Reflecting on the investigation, it is noteworthy that since the 2015 Morecambe Bay Investigation, criticism of maternity services for inadequate investigations and insufficient learning from past incidents has persisted. Bereaved families should not have to fight for comprehensive and transparent reviews; they deserve assurance in the processes surrounding such devastating outcomes.
**Contentions Around Home Birth Guidance from NHS England**
NHS England has also put forth proposals that might permit midwives to withdraw services from women opting for home births, particularly if such choices go against clinical advice. This consideration follows results from a coroner’s report and could extend to care scenarios deemed “highly unsafe or unreasonable.”
Critics of the proposals worry that this approach could lead to an increase in “freebirths,” where women deliver without professional assistance. The Royal College of Midwives has expressed concern that withdrawing care could compel women to give birth unaided, thereby raising risks for mother and infant alike. Charity Birthrights has branded the proposed guidance as a potential “erosion of human rights by stealth.”
**Hospital Overcrowding and Safety Concerns**
In further developments, the situation at St Andrew’s Hospital in Northampton remains precarious as NHS England has declared an end-of-June deadline for relocating a significant number of high-risk patients. This follows previous directives to transfer nearly 300 individuals, prioritising forensic patients not hailing from the Midlands, those in non-specialised commissioning beds, and patients clinically ready for discharge.
The hospital, which has not accepted new patients since last summer, has undergone scrutiny due to a CQC rating of “inadequate” and faces three police investigations related to allegations of abuse and neglect.
Amid these challenges, reports indicate that hospitals have begun utilising advanced practitioners—often senior nurses—to fill gaps traditionally held by physicians, which raises additional patient safety concerns. Data from the British Medical Association indicates that nearly half of hospital trusts employ advanced practitioners in roles within accident and emergency, critical care, and neonatal units.
NHS England has clarified that advanced practitioners are “highly skilled practitioners and are valued members” of healthcare teams, but stress that these roles should not substitute for doctors’ responsibilities and should be aligned with their competencies.
**Call for Systematic Changes in Mental Health Services**
Recent findings from the Health Services Safety Investigations Body (HSSIB) have identified significant issues in community mental health services. A report detailed a case involving a suicide attempt that underscored problems with information sharing among services, delayed identification of necessary support adjustments, and uncertainty about prescribing in the context of substance use.
The HSSIB report further highlighted that staff working in these community teams frequently experience emotional distress and lack the necessary support in the aftermath of challenging incidents.
**Patient Experiences Highlight Urgent Need for Care Consistency**
The Birth Trauma Association relayed a harrowing account from a woman named Katie, who suffered multiple postpartum haemorrhages, illustrating the critical need for continuity in maternity care. After being readmitted due to severe bleeding, a delay in accessing ultrasound services meant a retained placenta was undetected for several days, leading to further complications and emergency surgery. Reflecting on her experience, Katie noted, “I nearly died because it was a Saturday,” emphasising the need for reliable access to care irrespective of the day of the week.
This story serves as a poignant reminder of the necessity for enhanced, seven-day diagnostic and specialist services within maternity care systems, an issue that many expect will be at the forefront of discussions led by Baroness Amos and her team.
**Campaigns for Safer Healthcare Practices**
Lastly, a new campaign is gaining traction, advocating for stricter regulations surrounding medical cannabis prescriptions, particularly for clients with serious mental health conditions. Spearheaded by Xander Robinson, who lost his brother Oliver due to regulatory oversights, the campaign seeks to address potential vulnerabilities faced by patients.
In more positive news, the Baby Lifeline announced the UK MUM (Maternity Unit Marvels) Awards 2026, recognising exceptional contributions from healthcare professionals in maternity and neonatal care. Additionally, applications for the Joint Commission International Global Patient Safety Awards are now open, inviting innovative healthcare organisations to showcase their effective solutions for enhancing patient safety.
This edition concludes with appreciation for those who supported recent charitable efforts, further underscoring the commitment to improving maternal and patient care across the healthcare landscape.
Our Thoughts
To avoid the tragic outcomes referenced in the article, several key actions could have been implemented. Firstly, improved risk management protocols should be established, ensuring regular training for maternity staff on recognizing and responding to potential complications, particularly for high-risk groups, including Black and Asian women. This aligns with the Health and Safety at Work Act 1974, which mandates that employers must ensure the health, safety, and welfare of their employees and those affected by their work activities.
Secondly, the introduction of clear and standardized communication channels among healthcare professionals could mitigate missed diagnoses and monitoring failures, thereby preventing delays in patient care and enhancing overall service delivery, as stipulated in the Care Quality Commission guidelines.
Moreover, regulations related to the transparent investigation of adverse events should be more rigorously enforced to foster a culture of learning rather than assigning blame, thereby addressing concerns from families necessitating independent inquiries.
Lastly, ensuring adequate staffing levels and maintaining a balanced skill mix, particularly avoiding reliance on advanced practitioners to fill critical doctor roles in emergency settings, is crucial for patient safety and falls under the provisions outlined in the Nursing and Midwifery Council’s standards of practice.
