Patient Safety & Performance Science within Maternity Care

In 2015 the Morecombe Bay Report was published, highlighting the failures in care that led to the tragic deaths of 16 babies and 3 mothers at Furness General Hospital between 2004 and 2013. One of these, Joshua Titcombe, became particularly high profile as his father James has been very influential in campaigning for improvements in maternity safety and released a moving book “Joshua’s Story”.

As an expectant father of our first child due in just a few weeks, I cannot even begin to imagine the level of emotional trauma associated with such an event for all involved. Quite apart of that, the financial implications are also huge – in 2017/18, the figures released by NHS Resolution showed:

• obstetric claims totalling a staggering £2.16 billion from just over 1000 claims,

• representing 10% of the total number of claims

• and over 48% of the total value of claims across all disciplines.

• 71% (674 in total) of instances of stillbirth or death shortly after birth were preventable with better care (2018 Each Baby Counts review)

In November 2015 the government announced an ambitious target to halve the number of stillbirths, neonatal deaths and brain injuries by 2030, and a tremendous amount of work has happened in the last 3 years in working towards that.

• In 2016/2017 Health Education England provided £8.1 million of funding for maternity safety training (MSTF).

• In 2016 a 'Saving Babies’ Lives' Care Bundle was released, and independent evaluation showed an average of 20% reduction in stillbirths in the 19 units the bundle was trialled in. Version 2 of the SBLCB has recently been launched and mandated for all NHS trusts.

• In 2018 the new Healthcare Safety Investigation Branch began investigating all cases of stillbirth, maternal death and hypoxic brain injury; and have recently begun sharing the lessons from those investigations.

There is of course still much work to be done. In 2018 the Royal College of Obstetricians and Gynaecologists’ Each Baby Counts program published a review finding that 71% (674 in total) of instances of stillbirth or death shortly after birth were preventable with better care.

The charity Baby Lifeline, who themselves run some fantastic training around implementing the SBLCB and CTG Interpretation, identified significant gaps in the consistency and quality of maternity training.

A particular focus of the Morecombe Bay report was on the poor working culture within the multidisciplinary teams, and it is now widely acknowledged that all trusts need to invest in high quality MDT training that has a strong focus on Human Factors and High Performing Teams. Many trusts reported improvements in communication, confidence and team working as a result of training in Human Factors made possible with the HEE funding in 2016, though many have struggled to sustain improvements. An evaluation of the MSFT cautioned that without ongoing financial support there is a risk that benefits will diminish.

Extremely useful training – Excellent! Ben is a compelling teacher and truly understands how to enhance our ability to improve patient safety, through utilising a whole range of methods/skills/tools. A game changer, would absolutely recommend to others. Thank you!

- Toby Cooper, Head of Midwifery, North Devon District Hospital

Another concern raised by the Each Baby Counts program was the quality of local investigations, and this was supported by a review from NHS Resolution concluding the internal investigators had little or no formal training. Whilst the external eye from HSIB is enormously beneficial, many incidents fall outside of their remit and it is vital that we better training & support internal investigators in being able to conduct these with a Human Factors eye, being able to understand and analyse human-system interactions.

The UK still lags behind 23 other high-income countries with our stillbirth rates, and the new health secretary has stated a bold ambition to become the safest place to give birth. I have no doubt that with the amazing talent within our NHS this is possible, with the right strategies in place. We are delighted to be working with a number of organisations to implement sustainable strategies to make Human Factors and Performance Science 'business as usual', as well as delivering training in developing high quality incident investigations. Right now of course a lot of my attention is on our own upcoming new arrival – and having spent many days in labour wards and birth centres in a professional capacity I need to try switch the 'work brain' off for that experience!