DELAYS in crucial interventions during labour were a contributory factor in 14.9 per cent of 289 maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries, according to an investigation report by the Healthcare Safety Investigation Branch (HSCIB).
Several key national reports on maternity safety, such as those published by the Each Baby Counts Programme, were reviewed as part of the investigation and the findings suggest recurring themes that underpin delays to intrapartum intervention.
Loss of ‘situation awareness’ is cited as a common theme, with the focus often placed on the individual staff member and training recommended. The report states that this should "more appropriately be seen as the outcome of interactions between staff and all other elements that make up a work system and hence is an organisational issue".
The report’s findings were also informed by observations at two NHS trusts, interviews with NHS staff, subject matter advisors and those working at a national level in maternity safety. Rather than examine further examples of when things had gone wrong, the investigation looked at what enables things to go right and so help foster improvement.
One recommendation resulting from the investigation has been made to the Care Quality Commission (CQC) on assessing factors such as teamwork and psychological safety in its regulation of maternity units. Based on the evidence gathered, the report sets out a series of questions to consider in order to help staff identify strengths and opportunities for improvement.
Dr Louise Page, Maternity Clinical Advisor at HSIB, said: "Our approach with this investigation was to understand what can help things work well and examine factors within a maternity unit that can promote consistent safe performance despite the fluctuating demands of circumstances. The investigation also identified that there may be opportunities to share learning from Trusts that had made changes that had appeared to have a positive impact on managing the risk of delays.
"We recognise that work to mitigate these delays is a key focus nationally and feel that this report adds a valuable perspective on organisational resilience."
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