The Maternity and Newborn Safety Investigations programme (MNSI)
has today published a report identifying the main factors
affecting the delivery of safe care in NHS hospital midwifery
units.
The report – ‘Factors affecting the delivery of safe care in
midwifery units' – looks at the findings from 92 MNSI
investigations where safety recommendations were made to midwife
led units in NHS hospital trusts in England. It highlights key
learnings and prompts to help trusts to consider how safety risks
can be mitigated and drive improvements in care.
Based on an analysis of 92 MNSI investigations completed on or
before 14 June 2022*, the report identifies the following four
common themes as issues impacting on maternity safety:
-
Work demands and capacity to respond – the
number of tasks needed to be done and whether there are enough
(and suitable) staff, and appropriate physical space, to do
them.
-
Intermittent auscultation – a method used to
assess a baby's heart rate as an indicator of their wellbeing.
-
How prepared an organisation is for predictable
safety-critical scenarios, and the role played by in
situ simulation (a training method that involves staff
rehearsing scenarios in the workplace).
-
Telephone triage – the assessment a midwife
carries out when a pregnant woman telephones because they have
gone into labour or have a concern about their pregnancy.
These themes are illustrated by excerpts from the investigations
analysed. For each theme, there is also a set of safety prompts
to be used alongside clinical guidance by staff working in and
leading maternity services. The aim is to promote and support
learning discussions within midwifery units and staff in other
birth settings, and to influence the development of systems and
processes to improve safety.
Sandy Lewis, MNSI Director said: “Today's
report shares important safety observations from our
investigations in midwifery units and aims to help trusts do all
they can to ensure the safest possible care is provided. Our
investigations have demonstrated very clearly how supporting
staff through appropriate training, ensuring consistent and
robust triage processes are in place, and implementing an
effective fetal heart monitoring approach are all critically
important.
“While the report draws on analysis of incidents specifically
involving midwife led units, all maternity services must
prioritise actions to mitigate safety risks regardless of the
setting or mode of birth. As such, the learning we highlight is
equally as relevant to other birth settings, including hospital
obstetric units, and we hope the report will prompt discussion
and reflection among professionals across the sector.
“MNSI has a responsibility to families who have received care
and may use maternity services in the future, to understand what
happened and why, and to share learning to support service
improvements. I am incredibly grateful to the families whose
experiences are included in this report and to the healthcare
staff who participated in the investigations.”
ENDS
Notes to editors
- For more information and to access the full report, please
visit https://www.mnsi.org.uk/publications/factors-affecting-the-delivery-of-safe-care-in-midwifery-units/
from 09:00am Wednesday 8 May 2024. An embargoed copy of the
report can be found by clicking the link at the very bottom of
this email.
- *At the time of carrying out the investigations in this
report, the MNSI programme was still part of the Healthcare
Safety Investigation Branch (HSIB). In October 2023, MNSI moved
to be hosted by the Care Quality Commission (CQC).
- You can read more about what MNSI investigates and how
investigations are carried out on MNSI's website:
www.mnsi.org.uk
- MNSI uses the feedback of families and staff to review and
improve the way they carry out investigations. All family members
are welcome to give feedback. Find out how to give feedback
online or via post: https://www.mnsi.org.uk/for-families/family-feedback/
Maternity and Newborn Safety Investigations programme
(MNSI)
MNSI is the leading body for maternity and newborn safety
investigations in England. The Maternity and Newborn Safety
Investigations (MNSI) programme investigates certain cases of:
- early neonatal deaths, intrapartum stillbirths and severe
brain injury in babies born at term following labour in
England.
- maternal deaths in England.
The programme of investigations into maternity and newborn safety
incidents was previously overseen by the Healthcare Safety
Investigation Branch (HSIB). It began in 2018 as part of the
national initiative to improve safety in maternity care. From 1st
October 2023, MNSI has been hosted by the Care Quality
Commission. There has been no change to how hospital trust
maternity services in England refer incidents or concerns to the
MNSI team. The MNSI team continues to investigate and report
their findings in the same way.
