Summer Maternity Safety Newsletter

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Greater Manchester and Eastern Cheshire

Strategic Clinical Networks

Summer Maternity Safety Newsletter 2021

Issue 7




Welcome to the Summer Maternity Safety Newsletter with updates from the National Safety Programmes and local work streams. 

Maternity Safety

chantal knight

A busy spring has evolved into a even busier summer with an added third wave of Covid-19  affecting staffing across maternity units and the wider NHS footprint nationally and of course locally in Greater Manchester. Added pressures of increased birth numbers ,acuity and staff vacancies have compounded the situation. The continued ask of national and regional teams to provide intelligence and complete assurance requirements have proved to be a challenge for all maternity providers and the Local Maternity System(LMS) in these challenging times. Workstreams including Health Innovation Manchester(HIM) MatNeoSIP Quality Improvement work have been understandably been delayed with an agreement to pick up when it is safe to do so.

The Strategic Clinical Networks' Maternity Network and Health Innovation Manchester will continue to support maternity providers as requested and with the ongoing maternity safety agenda.


Chantal Knight

Maternity Safety Lead

Greater Manchester and Eastern Cheshire (GMEC) Strategic Clinical Networks/Health Innovation Manchester


Ockenden Report update


KEY MESSAGE: Further work required to demonstrate compliance to the 7 Immediate and Essential Actions(IEA)

Across GMEC all maternity providers are continuing to work on implementing the IEA’s and the GMEC Local Maternity System (LMS) continues to support them to successfully achieve all the requirements.

Bids have been submitted for the national Ockenden funding which will provide financial assistance for midwifery staffing; increased consultant time to cover twice daily ward rounds and multidisciplinary training.

The portal submissions were completed at the end of June by all providers with the detailed evidence of compliance to all 7 IEA and are currently being reviewed by the regional Midwifery Team.



NHS Resolution CNST Maternity Incentive Scheme

NHS Resolution is operating year four of the Clinical Negligence Scheme for Trusts (CNST) - a maternity incentive scheme to continue to support the delivery of safer maternity care.

The maternity incentive scheme applies to all acute Trusts that deliver maternity services and are members of the CNST. As in previous years, members will contribute an additional 10% of the CNST maternity premium to the scheme creating the CNST maternity incentive fund.

As in year three, the scheme incentivises ten maternity safety actions. Trusts that can demonstrate they have achieved all of the ten safety actions will recover the element of their contribution relating to the CNST maternity incentive fund and will also receive a share of any unallocated funds.

Trusts that do not meet the ten-out-of-ten threshold will not recover their contribution to the CNST maternity incentive fund, but may be eligible for a small discretionary payment from the scheme to help them to make progress against actions they have not achieved. Such a payment would be at a much lower level than the 10% contribution to the incentive fund.Trusts must submit their completed Board declaration form to NHS Resolution by 12 noon on 30 June 2022.

Progress to the 10 safety actions will be monitored by the LMS and any support required will be given. Detailed information on the updated changes has been shared with all provider.


HSIB’s maternity programme: a year in review

The review covers everything from operational performance to planned developments in the coming year (2021/22).

There are key sections on family and NHS staff engagement – focusing on their experiences of working with us, including how we gather their feedback and sharing direct quotes.

The review also sets out how HSIB fits into the wider maternity picture, explaining the way it works with other organisations and the contributions it has made to high-profile initiatives, projects, inquiries and reports.

HSIB’s unique perspective is also highlighted in the review. Its national remit combined with the insight it has into local maternity services means it is able to identify emerging safety risks and themes that can be found across England.

Over the last year, maternity investigation reports have contained 1,500 safety recommendations to trusts, addressing an array of issues and the most frequent emerging themes. This includes:

  • effective escalation of safety concerns about mothers and babies,
  • clinical oversight,
  • clinical assessment and monitoring,
  • use of clinical guidelines influence the care provided,
  • impact of pathways of care crossing healthcare boundaries.

Another key area to the report was the sharing of learning from individual trusts in maternity safety, including examples of changes that have been undertaken. HSIB has recently developed and shared a newsletter with trusts from across England, providing examples of improvements made to maternity services as a result of its recommendations.

This represents the influence and impact that HSIB is having on the day-to-day operations of NHS maternity departments.

Further detail:

HSIB_Maternity_programme_year_in_review_2020-21_Report_V29.pdf (

New report highlights fetal heart rate monitoring equipment issues in maternity care across NHS

HSIB launched a national patient safety investigation into the suitability of equipment and technology used for continuous fetal heart rate monitoring during labour and birth.

Multiple methods and types of equipment are used to continuously monitor fetal wellbeing during labour and birth.

This can cause complexity and safety issues. Common safety issues have been identified with equipment availability and functionality, inability to interpret the fetal heart rate, and staff understanding of equipment and its purpose.

Key findings in full

  • There is variation in the way trusts approach the procurement of equipment and in the use of multidisciplinary team working during the procurement process.
  • There was a lack of use of change management processes by trusts to help ease new processes/equipment into service.
  • Multiple manufacturers produce monitoring equipment with multiple specifications.
  • There is no consistent approach to training for maternity staff on the equipment they use.
  • There are no competency checks for maternity staff on the operation of CTG monitoring equipment (there are checks on their ability to analyse the output of CTG machines).
  • Centralised monitoring is often installed and used with no clear understanding of its purpose or clearly defined roles and responsibilities for staff using it.
  • National guidance has inadvertently influenced some trusts’ procurement decisions, which has in some cases resulted in financial cost.
  • Link to full report:Suitability of equipment and technology used for continuous fetal heart rate monitoring | HSIB

Saving Babies Live Care Bundle(2)

Providers are continuing to comply with Saving Babies Lives 2 (SBL2) in full, however some of the requirements need funding to sustain them and providers are being encouraged to discuss local funding with their commissioners.

Further work is required in order to embed the changes developed so far. This includes learning from incidents relating to the SBL2 Care bundle and these cases will now be fed into the Safety SiG.

Further work is ongoing in terms of the metrics required for SBL2 and the aim is to develop standardised definitions for each of the metrics so that all providers are measuring the same outcomes.

A large piece of work is about to start relating to training. This will include further developments to the Uterine Artery Doppler and Fetal monitoring training.

The SCNs' Maternity Network is also working alongside universities in GM in order for the training to be aligned with the undergraduate midwifery curriculum. Further work is planned for obstetric training.

Eileen Stringer

Clinical Lead Midwife    

Greater Manchester & Eastern Cheshire Strategic Clinical Networks

Continuity of Carer


Regular meetings have been in place with GMEC Heads of Midwifery, LMS, Strategic Clinical Network and regional leads since the start of the Covid-19 pandemic.

Since early June 2021, these have flagged that a number of providers have experienced growing pressures within maternity services in relation to workforce and growing levels of activity.

Due to the current pressures within maternity services some providers have had to amend or suspend some aspects of care, such as intrapartum CoC and that most providers will hold their current position where safe to do so rather than look to progress CoC models until current pressures have eased.


Eileen Stringer

Clinical Lead Midwife    

Greater Manchester & Eastern Cheshire LMS

Covid Oximetry @ Home for Pregnant Women

The Covid Oximetry @ Home service has been extended to include all pregnant women. This offer includes women being offered a pulse oximeter which they use three times a day to measure their blood oxygen saturations levels with a small monitor placed on their index finger. They are contacted daily for 14 days by a non clinical member of the Covid Hub to check their well being and signpost for additional support or any concerns. 

A new pathway for pregnant women , Covid-19 positive and on the Covid Oximetry @ Home service has been created to be used in Greater Manchester and East Cheshire. This new pathway recommends pregnant women have enhanced escalation straight to maternity services if the blood oxygen levels are below 94 or less. Full multi-disciplinary engagement and assessment of the woman will be required between the respiratory ,obstetric and midwifery colleagues to provide the most appropriate treatment an place of care.

Pregnant women with Covid-19 should be offered the following information leaflet and all maternity staff should be made aware of this new service and the importance of early assessment if they contact maternity services with any concerns

Details of the leaflet here:


Covid-19 Vaccination for Pregnant Women

KEY MESSAGE-Promote Covid-19 vaccination to all pregnant women



The uptake of the offer of the Covid-19 vaccination is being highlighted as an area of focus to improve the outcomes for women and their babies.

During July more than 100 pregnant women were admitted to English ICUs with Covid-19. Many more were admitted to other wards with babies being delivered prematurely to improve outcomes for their mothers.Additionally an increase in stillbirth's is seen in non vaccinated women with Covid-19.

There are substantial demands on maternity at present and these are compounded by the need to care for pregnant women with Covid-19. A concerted effort to vaccinate women will help to ease these pressures.

Vaccination should be offered, discussed and signposted at every antenatal contact ensuring first and second doses are completed and recorded.


2021-06-30-coronavirus-covid-19-vaccination-in-pregnancy.pdf (

talking-to-women-about-the-vaccine.pdf (


As part of the COVID-19 communication strategy for the North West, the North West Regional Maternity Team developed key messages for women in different languages. Whilst recording these key messages to create video resources of the messages, it took the opportunity to record a vaccination message for pregnant women, which has been translated into seven languages and includes subtitles.

These short videos are now accessible through the QR code we used for the Covid-19 key message, which takes you to the NHS E/I North West Maternity landing page.  However, here is the direct link to the videos, if you need it.


£7.5m study into Covid-19 dose intervals for pregnant women

A new Government-funded clinical trial investigating the best Covid-19 vaccine dose interval for pregnant women, has been launched in England.

This follows on from 130,000 pregnant women being vaccinated in the US without any safety concerns raised. The Pfizer/BioNTech and Moderna vaccines have since been recommended by independent experts at the Joint Committee on Vaccination and Immunisation (JCVI) for pregnant women in the UK.

In England, almost 52,000 pregnant women have now been vaccinated with no safety concerns reported.

According to data published by NHS England and the University of Oxford last week, no pregnant women who had both doses of a vaccine, were admitted to hospital with Covid-19. Only three women were admitted after having their first dose, but 98% of those admitted to hospital have not received a jab.

The Preg-CoV study is backed by £7.5m of Government funding, and is led by St George’s, University of London, who will provide important clinical trial data on the immune response to vaccination at different dose intervals. This could be at either four to six weeks or eight to 12 weeks.

Manchester Smoke Free

jane C

New figures reveal smoking in pregnancy rates at all-time low in Greater Manchester

New NHS data shows the number of people smoking during pregnancy in GM has dropped to the lowest on record.

Smoking at the Time of Delivery (SATOD) rates have fallen by around a quarter in the past four years - down from 1 in 8 (12.6%) new mothers in 2017-18 to fewer than 1 in 10 (9.8%) in 2020-21[1], meaning 945 more babies were born smokefree.

It shows the success of the Greater Manchester Health and Social Care Partnership's Smokefree Pregnancy programme which was set up in 2018 and is recognised as best practice nationally.

In the 12 months between April 2020 and March 2021, the programme supported more than 1,700 people on their journey to stop smoking, including pregnant women and their partners, and saw a 65% successful quit rate.

The programme was created as part of efforts to give every baby the best start to life. NHS maternity staff in Greater Manchester are given comprehensive training to have open and honest conversations about the risks of smoking, use carbon monoxide (CO) screening to check for exposure to tobacco smoke and refer people who need help to a maternity-led stop smoking service.

Smoking during pregnancy or inhaling second-hand smoke from others (known as passive smoking), can raise levels of carbon monoxide (CO) within the body. This poisonous gas can restrict the essential oxygen supply to the baby and significantly increase the risk of complications such as miscarriage, premature birth, low birth weight and stillbirth.

During the pandemic, the number of women referring themselves to the stop smoking service increased, and personal carbon monoxide monitors were issued, allowing service users to complete CO screenings at home that linked through to a smartphone app which the specialist midwives could track to validate their quit journey.

Photo above right: Jane Coyne, Strategic Lead for the Making Smoking History and Smokefree Pregnancy Programmes

Long Term Plan Programme Implementation Advisor - Tobacco Dependence  NHS England & NHS Improvement


New report emphasises that pregnant and postnatal women with Covid-19 must receive the same standard of care as non-pregnant people

Findings from the new MBRRACE-UK 2021 rapid report, Learning from SARS-CoV-2-related and associated maternal deaths in the UK June 2020-March 2021 , suggest there needs to be wider awareness of how best to treat pregnant and postnatal women with Covid-19.

Report authors reviewed the care of all pregnant and postnatal women who died with SARS-CoV-2 infection, and women who died and whose care or engagement with care was influenced by changes as a consequence of the pandemic between 1 June 2020 and 1 March this year.

Fourteen women died with SARS-CoV-2 infection, 10 from Covid-19 and four from other causes, three further women's deaths were influenced by changes as a consequence of the pandemic.

Only one out of 10 women who died from Covid-19 was treated in accordance with the evidence-based guidance developed by the Royal College of Obstetricians and Gynaecologists and Royal College of Midwives.

This comprehensive national guidance should be followed wherever pregnant or postpartum women are cared for. The report also highlights a need to ensure early senior involvement of the maternal medical team, understand the needs of the woman herself and avoid withholding treatment due to misplaced concerns over her pregnancy.

The report also noted ongoing indirect impacts such that women are fearful of seeking care and may delay presentation or not present at all. Other pregnancy complications remain many times more frequent than Covid-19 in pregnancy, and the need to ensure women are able to access the care they need is essential.

This includes making sure that women are confident about their safety in attending face to face visits, but also recognising situations in which remote consultations are inadequate. This may be for several reasons including language difficulties, lack of access to appropriate technology, repeated presentation, clinical complexity or potentially severe or high risk conditions.


MBRRACE Online Course 2021

MBRRACE will be running two free courses simultaneously over 6 weeks during September and October 2021.

  • One course will cover the lessons from the 2020 MBRRACE-UK Perinatal Confidential Enquiry and the Perinatal Mortality Surveillance Report.
  • The other course will cover lessons from the 2020 MBRRACE-UK 'Saving Lives, Improving Mothers' Care' report.
  • Each week will focus on a specific topic. The relevant presentations from the 2020 MBRRACE-UK report launch meetings will be available on the MBRRACE YouTube channel (these will be available for two weeks from the release date), along with the relevant chapters of the report and the presentation slides.

    Please email to sign up to receive further notifications about the course, including weekly emails when new presentations are made available; or for any further enquiries.


In Focus:Safety Culture development programme for leaders of maternity and neonatal services

The MatNeoSIP delivery team at Health Innovation Manchester appreciate that maternity and neonatal units are under increased pressure at the moment and therefore will not be adding additional pressures by chasing those improvement teams who currently are unable to engage with regards to their MatNeoSIP improvement projects. We look forward to continuing supporting teams when it is safe and appropriate to do so.

Trust Improvement Teams have completed day three of the Patient Safety Improvement Practitioner Programme, the methodology on day three included measurement for improvement and PDSA cycles. Teams are now able to develop a measurement strategy and undertake small scale tests of change using PDSA cycles (when they have capacity to re-engage).

Following initial prototype testing, supported by the maternity team at Oldham, the new national MEWs tool has been finalised and is ready for the next phase of testing. We are currently awaiting further instruction from the national team regarding what specifically the next phase of testing looks like. We will likely call upon interested maternity units within our LMNS to support with this phase of testing.

We would like to thank Simon Meghan, Director of Midwifery, Karen Parks, Interim Labour Ward Lead Midwife and Karen Parks, Practice Educator at Oldham, for supporting us and the national team with the initial prototype testing process.

We are in process of engaging with the colleagues in the system regarding our delivery model for 2022/23 when we shift our focus to the optimisation workstream and look at preterm the optimisation pathway. We will undertake this engagement via HoMs and one to one meetings with the patient safety lead midwife.

Working collaboratively with the Greater Manchester Health and Social Care Partnership and smoke free specialist midwives from across the LMSN, we have developed a driver diagram with the aim being to increase CO monitoring at every contact in line with national standards. Over the coming months we will be working with specialist smoke free midwives at each maternity unit to undertake small scale tests change based on the change ideas identified in our driver diagram.

Our third Patient Safety Network Learning Event will take place on the on November 11 2021 and will be a joint event with the Strategic Clinical Networks (combining the Patient Safety Network Learning Event with the GMEC LNMS Patient Safety Showcase Event). The patient safety focus for this event will be on reducing inequalities. Further details regarding how to register for the event will be released in the coming weeks


If you have any question regarding MatNeoSIP please contact

Tom Openshaw Programme Development Lead Patient Safety Collaborative, Health Innovation Manchester.


Preventative Maternity Care-Increasing Safer Outcomes

Vitamin D Supplements-Providers taking action


Greater Manchester and Eastern Cheshire Local Maternity System (GMEC LMS)  was the only LMS involved in a recent pilot of the Peppy Baby app. 

The lead maternity provider St Mary's Managed Clinical Service worked with stakeholders across Manchester, Trafford and Salford with support from the SCN Maternity team on the pilot of the Peppy Baby app.

This was for those in late pregnancy through to eight weeks post birth, providing additional free expert support including 1-2-1 text chat with perinatal practitioners, infant feeding consultations, mental health advice, tailored group webinar sessions on a wide range of topics, peer support group chat and more. 

The external evaluation by Swansea University found positive outcomes for the support the app provided to parents as well as positive outcomes for infant feeding, mental wellbeing and parental confidence. 

Some of the outcomes included:

  • At eight weeks, 80% of women were breastfeeding, (this is higher than the average across Greater Manchester)
  • 95% said Peppy helped them feel more knowledgeable about breastfeeding
  • At eight weeks, 82% of parents were feeding their babies as they had planned (importance of this on parental wellbeing)
  • Mental wellbeing improved during the pilot, with the percentage of mothers reporting normal or high wellbeing increasing from 69% at baseline to 89.9% at the end of the pilot. There was a particularly high increase in mental wellbeing at end of the pilot from those of Black, Asian or minority ethnic background 
  • 90.5% reported Peppy Baby gave them greater confidence in their parenting
  • 92.8% said they would like to see Peppy Baby continue.

If you are interested in receiving the full evaluation report, once this has been released, please email

Up Coming Events

16th September 2021 HSIB National Investigation Conference via Zoom. To book a place follow link: Webinar Registration - Zoom

11th November 2021 LMS/HIM Safety Event via Teams 9.30-16.30 Further details from