Trends in maternity investigations 2021/2022

Written by Kaya Gillard on 17th January 2023 | 11 minute read

The Healthcare Safety Investigation Branch conducts independent investigations into patient safety concerns across the NHS. Safety recommendations are often made by HSIB as a result of their investigations, with the aim of improving patient safety within the healthcare system and reducing risk to patients.

The Maternity Investigation programme started in 2018 as part of a national care plan to make maternity care in England safer. HSIB works with over 125 different Trusts, who refer cases for investigation with the aim of working together with HSIB and the families involved to improve safety within maternity care.

Cases involving term pregnancies and one or nore of the following are eligible for investigation by HSIB:

Intrapartum stillbirth (where the baby was thought to be alive at the start of labour but was stillborn). Read more about Stillbirth and neonatal death compensation claims | Tees law
Early neonatal death (where the baby died within the first week of life). Read more about Stillbirth and neonatal death compensation claims | Tees law
Severe brain injury (where the baby was diagnosed with severe brain injury in the first 7 days of life). Read more about Brain injury at birth: Signs, symptoms & causes | Tees Law
Maternal deaths (death of a woman whilst pregnant or within 42 days of the end of the pregnancy from any cause related to or aggravated by the pregnancy). Read more about Birth injury negligence claim solicitors | Tees Law

If you have experienced any of the above, or any other problems during your pregnancy and/ or birth and would like to speak to a lawyer about it, our dedicated team of specialist medical negligence lawyers are here to support and assist you throughout the process on a no win no fee basis (Medical Negligence Solicitors | No Win No Fee | Tees Law).

During 2021/2022, HSIB received 731 referrals for investigations and completed 706 investigation reports, resulting in 1,740 safety recommendations to trusts addressing a wide range of issues.

The emerging themes and outcomes from the 2021/22 review of the Maternity Investigation are summarised below. Read the full report here hsib maternity investigation programme year in review 2021 22

Effect of Covid-19 on clinical assessments
Information sharing
Clinical oversight
Escalation of care
Fetal monitoring
Inconsistency in local and national guidelines
Plans for the future

Effect of Covid-19 on clinical assessments

The effect that the Covid-19 pandemic had, and continues to have on the NHS is undeniable. In the context of maternity care, clinical assessments were adapted in order to comply with national lockdown guidance. Where face-to-face appointments were not possible, Trusts adopted a practice of holding appointments via telephone or video call, which has continued and has now become a standard practice throughout many trusts.

Although convenient, telephone and video assessments can often lead to missed opportunities for clinicians to identify potential problems. It is not possible to undertake routine antenatal checks, e.g. urine tests, blood pressure checks, symphysis fundal height measurements, and abdominal examination to check the position of the baby during remote assessments and clinicians are not able to rely on subtle cues such as changes in behaviour, appearance or body language that might be more obvious in face-to-face appointments.

Not only did the report highlight the importance of antenatal face-to-face assessments, but it also highlighted that face-to-face reviews involving the multi-professional team and mother supported safe clinical oversight of her labour and birth. Similarly, involving parents in face-to-face reviews in the post-natal period optimised a baby’s care.

Read more about the effect that Covid 19 has had on other areas of the NHS, and how Tees can help, here; Medical misdiagnosis claims | Tees Law.

Information sharing

HSIB identified issues relating to the accessibility of medical records across different services, making it difficult for clinicians to access the clinical history, and previous clinical findings and to communicate with each other. For example, a maternity ward would not necessarily have access to ED records; and a hospital would not necessarily have access to GP records.

There were a number of cases where had the clinicians had access to the full clinical picture, they would have identified cumulative unexpected findings and changed the care plan.

Katheryn Riggs - Bishop's Stortford medical negligence solicitor, is supporting a mother who underwent a substandard emergency C-section which resulted in a bowel injury that required additional surgery. This client’s maternity records were not shared with the hospital that she gave birth in, and in any event were not sufficiently completed to include her relevant past medical history, which would have made a difference to the outcome had her medical records been correctly updated and shared.

Clinical oversight

HSIB recommended that Trusts adopt a ‘helicopter view’, with a designated member of staff maintaining an overview of each patient’s care. Specifically, this improves safety:

When documenting personalised care plans
When responding to investigation/scan results
During a clinical emergency
When a mother or baby moves between care settings and there may be changing care priorities

In response to this recommendation, a number of Trusts have updated their protocols to incorporate a helicopter view, to ensure that patients are reviewed within an appropriate timeframe and that all aspects of their care are taken into account.

Escalation of care

The report identified that there are many occasions when healthcare professionals do not recognise when it is necessary to seek the opinion of a more senior or specialist colleague. There are a number of reasons for this:

Trusts do not uniformly use, implement and respond to MEWS (the Maternity Early Warning Score)
Trusts have different policies and protocols which trigger an escalation
Trusts have inconsistent processes for considering referral and response when a mother attends non-maternity services, e.g. ED
Staff ‘normalise’ the evolving situation
The process of escalation can be hierarchical and it can be difficult for staff to know what to do if there is a difference of opinion

Tees have seen a number of cases involving failure to appropriately escalate a mother’s care.

Rachel Benton, Cambridge medical negligence solicitor, is acting for the family of a mother who sadly passed away following a delay in diagnosing pre-eclampsia. HSIB carried out an investigation and was critical of the Defendant Trust’s failure to correctly assess her risk level on admission and to calculate a Maternity Early Obstetric Warning Score (MEOWS). The Defendant Trust has accepted that, had the MEOWS system been used correctly, this would have prompted an obstetric review and increased monitoring of her blood pressure, leading to a diagnosis of pre-eclampsia. Had the pre-eclampsia been diagnosed, the mother would have avoided pre-eclamptic seizures and would have survived.

Sophie Stuart - Cambridge medical negligence solicitor, is supporting a mother whose symptoms of Chorioamnionitis were not considered or escalated appropriately during her labour. This meant that the Defendant Trust missed an opportunity to offer her a C-Section, resulting in the traumatic birth of her baby who suffered from shoulder dystocia and required resuscitation on delivery, and the mother experiencing a double prolapse requiring future surgery and Post Traumatic Stress Disorder.

Contributing factors included the failure to appropriately assign the mother to consultant-led care, the failure to move the mother to the labour ward due to a lack of staff, and the failure to provide an accurate handover.

Fetal monitoring

There continues to be concerns about the safety of fetal monitoring. Two key concerns were identified:

1. A failure to recognise or act upon a suspicious or pathological CTG

2. Failing to increase intermittent auscultation in line with national guidance in the second stage of labour

Natalie Pibworth - Chelmsford medical negligence solicitor, acts for a mother who had a ‘fortunate escape’ in surviving a post-partum haemorrhage caused by failures to identify and act upon a pathological/ pre-terminal CTG. Thankfully, her son was delivered in good condition, albeit 15 minutes after the CTG had become pre-terminal.

Inconsistency in local and national guidelines

HSIB identified inconsistencies with the NHS guidance that exist on both a local and national scale. There are areas of care where no national guidance is available, and as a result local Trusts often try to implement their own guidance to fill in the gaps. However, this can lead to varied standards of care across the NHS, with some Trusts relying on their own guidance, and others not having any guidance at all.

Given that the NHS lacks funding and resources in key areas, a number of Trusts are not in a position to implement or even produce their own guidance where it is needed. The lack of national guidance, therefore, means that these Trusts are left without any guidance at all in key areas of clinical management. Staff are then left unaware of the best way to respond in certain situations.

HSIB specifically identified that there is no national guidance on the management of mothers who are inpatients in the latent phase of labour. Some Trusts have introduced their own guidelines based on this; however, this does not necessarily address the gap across the whole of the NHS and risks inconsistency.

Plans for the future:

A Special Health Authority is due to be established in April 2023 to continue the HSIB Maternity Investigation programme with the aim of equipping NHS Trusts with the expertise, resources and capacity to take on maternity safety incident investigations in the future.

If you have any concerns regarding your own care and experiences throughout pregnancy and/ or birth, Tees’ Medical Negligence specialists are here to help.

Call our specialist solicitors on 0808 231 1320