Since commencing my post in December 2018 with the Greater Manchester and Eastern Cheshire (GMEC) Strategic Clinical Networks and Health Innovation Manchester my focus has been to make important links with all the maternity providers and organisations in GMEC.The importance of my work has been received with positivity and I have felt very welcomed to all the teams I am involved with, so thank you for this.

One of my main deliverables of the role is to establish a process for learning from maternity incidents and excellence across GMEC.

Sharing of learning across GMEC is vital if we are serious in our drive to improve outcomes for women and families accessing our services.

The creation of a system to provide an external reviewer to serious maternity incidents is now underway. The aim is to extract additional learning which can shared across all providers preventing harm from similar themes. We have asked for interested clinicians to join our team of external reviewers. All enquires to our dedicated email:

england.GMEC-Maternity-Review@nhs.net 

And finally, today is the first World Patient Safety Day - something close to all our hearts - and below you will find some personal messages from the team at the GMEC Strategic Clinical Networks about why patient safety matters to them. 

Chantal Knight

Maternity Safety Lead

Strategic Clinician Network/Health Innovation Manchester

Learning from Maternal Deaths in GMEC

A report on maternal deaths in 2018 for GMEC has been circulated to all heads of midwifery and governance leads. It is recommended each provider looks at the organisational learning to review their systems in place with regard to:

• What escalation pathway have you in place for referral to outside agencies for staff to follow including a target date for outcome?
• Do you have a failsafe in place with a robust process for follow up of all blood or specimen results?
• How do you monitor women who repeatedly do not attend (DNA) appointments across multiple specialities e.g. antenatal clinic , sonography , community midwives and general practitioners?
• Are clinicians aware of the specialist perinatal service based at GM Mental Health Trust (Laureate House) which is available 24/7 for advice regarding risks medication and potential admission to hospital for women with mental health issues?

Further learning from MBRRACE which publishes yearly reports on maternal deaths in the UK can be found here:

The next launch event for the 2019 report will be held in Birmingham on 19th November. More details here. 

NHS Resolution Learning

Latest learning from NHS Resolution case stories is available on the following here. 

One case has been highlighted for maternity services. Although this case occurred in an emergency department there is learning for maternity services, particularly in relation to triage and assessment of women on arrival to maternity facilities. GMEC have seen similar cases reported where delays prior to or after triage and a poor birth outcome has occurred.

Guidance published by the National Institute for Health and Care Excellence (NICE) in 2015 entitled ‘Safe midwifery staffing for maternity settings’ outlines examples of maternity red flags, and that a red flag should be considered when there is a ‘delay of 30 minutes or more between presentation and triage’.

Therefore the following should be considered by maternity services:

• Do you have a standard for maternity triage waiting times? If yes, is this clearly displayed for maternity patients and their birth partners to see on arrival to the maternity unit?

• Are clinical and non-clinical maternity staff aware of the standard for maternity triage?

• Are maternity receptionists trained and informed of their roles and responsibilities in relation to providing information about waiting times?

• In relation to good practice, how are red flags escalated and monitored within your maternity service?

PReCePT Programme

PReCePT is a national programme (2018 – 2020) designed to reduce cerebral palsy in babies by administering magnesium sulphate (MgSO4) to mothers during preterm labour.

The data has shown a slow increase from 43% uptake in 2016 to 57% in 2018.The roll out of the national PReCePT programme and the recruitment of clinical champions has demonstrated a sharp increase and exceeded the expected national standard of 85% which is fantastic progress across GMEC.

The success of the programme has been achieved by the dedication of the PReCePT champions supporting clinicians with training and advising women of the health benefits of having MgS02 at a very difficult and stressful time, often going above and beyond the expectations of the role in personal commitment. 

Approximately 140 out of the 150 babies who were eligible across GMEC from commencement of the PReCePT programme received magnesium sulphate and evidence indicates 4 babies would be prevented from developing cerebral palsy and a life time of disability for families, as well as a reduction in expensive and extensive healthcare provision.

The PReCePT champions deserve recognition for the dedication they have shown to this mission and they have been nominated them for the Chief Nursing Officer Silver Team Award with the endorsement of Julie Cheetham (Associate Director, GMEC Strategic Clinical Networks) and Richard Preece (Executive Lead-Quality, Greater Manchester Health and Social Care Partnership).

Further updates will be included of this nomination in the next newsletter. 

A GMEC PReCePT is under creation and will be shortly shared for roll out across the region to standard best practice and assist clinicians to maximise the number of women receiving MgS02.

SCORE Survey

In conjunction with the Maternal and Neonatal Health Safety Collaborative (MNHSC), a national quality improvement programme working with maternal and neonatal services across England, 87 trusts have carried out safety culture surveys. Collectively this is the largest such survey in England and provides a snapshot of the safety culture of maternal and neonatal services, highlighting areas of strength and where improvement may be needed. Happier teams provide better care to patients and it is now accepted that good culture in the NHS is crucial to ensure that patients receive high quality care and better outcomes.

As teams work to improve systems and processes, it is important that they better understand their own culture to identify what works well and what can be improved with a collective responsibility to drive change.

Following the safety culture survey, the MNHSC has supported all Trusts with debrief sessions to begin the conversation with their staff about what action and improvement should follow.

All providers are now being actively encouraged to create their local improvement plans and initiate quality improvement projects - ultimately it is up to your team to use the results effectively.

Patient Safety: a global health priority

On the first-ever World Patient Safety Day on 17 September 2019, WHO will launch a global campaign to create awareness of patient safety and urge people to show their commitment to making healthcare safer.

Today is World Patient Safety Day. No one should be harmed in health care. And yet, every day, thousands of patients suffer avoidable harm while receiving care.  If you are a midwife ,doctor, nurse, pharmacist or health worker, engage patients as partners in their care. Work with the patient to create an open and transparent patient safety culture. Encourage blame-free reporting and learning from errors. Speak up for patient safety!

Patient safety is about working to prevent errors in healthcare that can cause harm to patients. Harm in this context means injury, suffering, disability or death. The errors that occur in healthcare are rarely the fault of individuals, but are usually the result of problems with the systems they work in.

Magnitude

Up to 4 out of 10 patients are harmed in primary and ambulatory care settings

Incidence

134 million adverse events occur each year in hospitals , contributing to 2.6 million deaths annually due to unsafe care

Cost

Up to 15% of hospital expenses can be attributed to treating patient safety failures

Clear policies, organizational leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed to ensure sustainable and significant improvements in the safety of health care.

The LMS are working across all work streams to incorporate safety as a key goal and improve outcomes for women and their families.