November 2, 2021

HSIB Report: “Summary of themes arising from the HSIB Maternity Programme” – A review

The Healthcare Safety Investigation Branch (HSIB) is an NHS funded independent body who seek to investigate circumstances where the mother and/or baby have suffered an adverse event during pregnancy and/or childbirth. The Healthcare Safety Investigation Branch has released a series of reports into the risks and resulting issues that face maternity units, pregnant women and new born babies when in NHS care. These are known as the Maternity National Learning reports.

HSIB does not report on individual cases investigated, but rather collective themes that emerge from several investigations. By having an insight into the different themes, healthcare providers are able to identify areas of increased risk, and in turn should be able to focus on ensuring improvements to patient safety. These reports include recommendations that seek to reduce harm to mothers and babies, ultimately keeping patients safer.

In the summary report, the themes that have arisen relate to:

- “Early recognition of risk”, which conveys findings that a large proportion of those who have suffered adverse outcomes have often had their level of risk misinterpreted. While a vast majority of mothers are categorised as low risk, the report has found that as a pregnancy progresses, events and changes in circumstances can alter the risk level – however, these are not always recognised or factored into the care plans. An example included a mother attending hospital multiple times through her pregnancy due to vaginal bleeding and reduced fetal (baby) movement but being reassured that her pregnancy was low risk. Therefore, she was not assessed by a senior clinician as she should have been nor did she receive more in-depth monitoring with experienced staff.

- “The safety of intrapartum care”, which recognises the need for higher levels of care during labour, particularly for mothers who may be carrying group B streptococcus, babies who are small for the period of gestation and those who have previously reported a lack of movement. Findings show that maternity wards are often putting the “4cm rule” (the level of dilatation of the cervix) above other risk factors when deciding whether a mother should be admitted to the labour ward. Furthermore, it has been noted that some mothers are sent home with pain relief until they believe they are in established labour. The lack of continued monitoring of the baby has meant that in some cases, complications that may have been identified with higher levels of care are being missed.

- “Escalation of care”, which highlights the importance of using the skills and expertise of the whole team to provide the highest standard of care. Whilst there is a hierarchy that needs to be followed to escalate care, the report identifies a tendency to contact the senior clinician directly to assess the situation. Additionally, senior clinicians are seen more as a “fresh pair of eyes” rather than more experienced and knowledgeable, and they have been noted to not always be supportive and clear in their instructions to staff. Furthermore, when matters are escalated to clinicians, the investigations found evidence that it is often only the current situation considered rather than the history of the pregnancy and increased risk factors can go unnoticed.

- “The quality of handovers” as a risk factor suggests that more needs to be done to ensure that important information is not missed during the handover of care, whether it is from one member of staff to another during shift change, or different areas of clinical care such as from the delivery suite to neonatal intensive care.

- “Babies of a larger size” who are at a higher risk of birth complications due to their size. The investigation has found that as larger babies are more likely to get stuck during birth (shoulder dystocia), they are then more likely to suffer from brain damage from a lack of oxygen and in most serious cases, death. It is important in cases where a baby is large that the mother is given all the necessary information to make an informed decision around their birth plan. Furthermore, while medical staff are trained on how to handle events such as these, findings show that not enough emphasis has been placed on how to predict these events and the procedures that need to be in place to minimise these risks.

- “Neonatal collapse alongside skin-to-skin care” which, in simpler terms, is the phenomenon where while the baby is having skin-to-skin contact with the mother immediately following birth, the medical team often are focussed on the mother’s postnatal care and completing all mandatory documentation and as a result miss any underlying issues or deteriorations in the new born baby. Subtle changes to the baby such as the baby turning blue and breathing irregularities are often overlooked during this crucial period for observation. The report recommends that medical staff take all concerns of the parent seriously and ensure that both mother and baby are observed to a high standard to ensure that any complications are picked up on in a timely manner to prevent any further issues.

- “Group B Streptococcus” (GBS) is an innocuous bacteria often found in the mother’s vagina that can cause serious infections in a baby. It is not currently viewed as routine to screen mothers for this during their pregnancies, however giving mother antibiotics during labour can be effective in preventing the baby from catching GBS infection. The report has found that as with issues of escalation, call receivers and clinicians frequently fail to identify that the mother has GBS and therefore fail to provide antibiotics in labour putting babies at increased risk of GBS infection.

- “Cultural considerations” - There is a five-fold increase in deaths amongst black women and a twofold increase in deaths amongst Asian women during childbirth. These rates are in part due to a lack of consideration of culture by medical staff when in the maternity unit. Misunderstandings and miscommunications between parties can create a risk of inappropriate care and can have catastrophic consequences for both mother and child. When translation services are not available, staff members who speak the native language are often used to interpret but this can lead to misunderstandings. It has been found that there is often the assumption that if a mother speaks “good English” she also has the capacity to understand it – this may not be the case especially with complex medical terminology that even native English speakers struggle with.

We are pleased to see that recommendations are being made in reference to the safety of both mother and child during maternity, particularly as we see cases involving such risk factors daily. We at RWK Goodman warmly welcome any changes that can be made to improve patient safety.

If you are involved with the Healthcare Safety Investigation Branch, the report following investigation of your case will be sent to the Early Notification Service (ENS) at NHS Resolution. The HSIB report forms part of a triage system in the NHS Legal Department assessing whether you may have a claim to bring.

If you would like further information on the HSIB reports and birth injury claims, you can click here to read our guide. Or you can contact us here for further, more tailored legal advice.

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