HSIB National Learning Report identifies themes in NHS maternity safety - but still no recommendations

HSIB has published its long-awaited first national learning report into maternity safety since taking over responsibility for investigating incidents of brain damage, stillbirth and neonatal injury to babies, and maternal deaths, in April 2018. The report identifies eight themes or common failings in maternity care which have led to devastating harm to mothers and babies around the time of childbirth but fails to provide recommendations to improve patient care.

What is the HSIB?

The Healthcare Safety Investigation Branch (HSIB) carries out independent investigations of patient safety concerns in NHS care. HSIB investigations examine healthcare systems and processes which have contributed or led to patients being harmed. HSIB’s role is to make recommendations which will improve healthcare systems and processes to reduce risk and improve patient safety. They investigate cases of harm to individual patients, as well as patient safety concerns across NHS care. They never attribute blame or liability to an individual. 

What is an HSIB learning report?

HSIB’s national learning reports use their findings from their investigations to provide insight and learning about patient safety risks in NHS healthcare. The national learning report is supposed to highlight recurring themes and make safety recommendations which will help NHS organisations and their staff make better decisions to improve patient safety.

Since 1st April 2018, HSIB have been solely responsible for over 1,000 NHS maternity patient safety investigations which meet the RCOG’s Each Baby Counts criteria. These include term babies who have suffered stillbirth, brain injury or neonatal death. HSIB also investigates birth-related maternal deaths. By December 2019 HSIB had only completed 280 investigations, with a further 145 investigations finished but being checked for accuracy by families and trusts. Recently, the government announced that HSIB will lose its maternity investigations remit, when it becomes an independent statutory body later this year.

What does the HSIB learning report on maternity safety say?

This report lists eight themes which have emerged from HSIB’s analysis of completed maternity investigations.

Theme 1 - Early recognition of risk

Failure to assess a woman’s risk status properly, and to increase her risk status when changes occur in the mother or unborn baby’s condition are a common feature of maternity safety reports. Where a mother or baby suffers harm because incorrect risk assessment has led to delay in taking necessary action, such as calling for help from a senior colleague or delivering the baby quickly, the injured mother or baby may be entitled to claim compensation.

HSIB found that many complications in labour or birth could be traced back to inadequate or inflexible risk assessments during the mother’s antenatal (pre-birth) care. HSIB found that many mothers experienced events or changes during their pregnancy which increased their level of risk, but these changes were not recognised or considered in later decisions about their care.

Factors affecting the mother’s risk status included:

• reduced fetal (baby) movements;
• changes in the mother’s physical or mental health which needed support;
• referrals to specialist services, which weren’t always followed up;
• fetal growth observations (such as fundal height measurements or ultrasound scan results) were not plotted on a growth chart to ensure that the baby’s growth is as expected;
• delays in following up test results.

HSIB found common errors in maternity staff’s assessment, monitoring and reaction to changes in risk status, including:

• failing to record and consider the factors listed above when the mother is admitted. This means the mother is then treated as low risk and doesn’t receive the correct level of care and monitoring.
• looking for reassurance that worrying new symptoms were not a concern.
• failing to review a mother’s new condition as a whole,
• delaying taking action in the hope that things will work out, instead of changing the mother’s risk status from low risk to high risk and taking appropriate action.

Theme 2 - Safety of intrapartum (childbirth) care

HSIB found that women in early labour were given differing advice when they contacted the maternity unit. Mothers who were already known to be high risk tended to receive better care but there were delays in reacting to high risk changes in a previously low risk mother’s or unborn baby’s condition. When a mother contacted the unit more than once, her records were not properly updated to ensure that each new clinician she spoke to was fully aware of her history and concerns.

Mothers were often told over the telephone to stay at home as they were in ‘early labour’, without a proper assessment of their condition as a whole. This meant that they didn’t receive the care that they needed, particularly for mothers:

• carrying group B streptococcus (GBS);
• with an unborn baby who is small for dates;
• with lack of fetal movements.

In many cases over-reliance on NICE guidance for low risk pregnancies, which says that labour is not established until the mother’s cervix is 4cm dilated, exposed higher risk unborn babies to an increased risk of complications during labour. HSIB emphasised that these babies need to be assessed when the mother starts to have strong contractions, because this is when the baby begins to feel the stress of labour.​

HSIB also found that mothers were sent home with signs of early labour to await ‘the establishment of labour’ after being given strong opioid pain relief which requires close monitoring of mother and baby. Many mothers who were sent home in early labour didn’t know when to come back to hospital. Many returned to hospital in advanced labour, missing the opportunity to identify signs of fetal distress and take early action to avoid injury.

Theme 3 - Escalation

As with other maternity safety reports, HSIB found that maternity safety was threatened by inflexible and inadequate escalation. Escalation is where a midwife or doctor calls for help from a more experienced colleague. Escalation problems included:

• requests for help having to move step by step up the ‘hierarchy of seniority’, for example where critical delays in delivery caused injury because the midwife was not permitted to call a doctor for help, but had to call the labour ward supervising midwife who then called the doctor;
• unclear responses from the senior clinician, leaving the staff not knowing what to do next, and affecting their confidence in asking for help in future;
• ‘fresh eyes’ reviews only considered the CTG trace instead of reviewing the mother’s overall condition;
• reviews were biased towards confirming the previously ‘normal’ assessment, instead of contradicting it and taking necessary action. 

In keeping with other maternity safety reports, HSIB found high numbers of escalation problems relating to fetal heart monitoring.

Theme 4 – Handovers of care

HSIB found that important information was lost during handovers of care from one individual or healthcare team to another. In some maternity units, maternity staff were not able to interrupt formal handovers to seek urgent help from a clinician who was involved in the handover. This caused delays in urgently needed patient care.

Theme 5 – Big babies

HSIB found that mothers with big babies were not properly advised of the risks associated with having a big baby. This left them unable to make informed choices about the method of birth for their baby. Whilst maternity staff had training in teams on emergencies during childbirth, this doesn’t give them enough understanding about how to anticipate or prepare for these emergencies. In particular, HSIB found that the need for neonatal staff to be present at the birth of a large baby was not always recognised in advance. Delays in calling neonatal team staff until after the baby was born may have contributed to injuries to the mother and baby.

Theme 6 - Neonatal collapse during skin-to-skin contact

In what appears to be a new, and highly concerning, cause of significant harm to newborn babies, HSIB reported that a number of babies, who were born healthy, suffered brain injury or died when their airway was obstructed by poor positioning on the mother’s chest during skin-to-skin contact immediately after birth. HSIB found that midwives became so focussed on completing documentation and providing maternal care immediately after birth that they didn’t properly, closely observe babies who were placed on their exhausted or sedated mother who was unable to physically see or hold the baby safely. Changes in skin colour, grunting and other signs of neonatal collapse require urgent action to avoid significant harm to the baby.

HSIB reports that UNICEF’s UK Baby Friendly Initiative maternity guidance on safe skin-to-skin contact has now been updated to include more information on maternal position, to mandate ongoing thorough monitoring of the mother and baby, and ensure that midwives listen to concerns raised by the parents about their baby’s condition.

Theme 7 - Group B streptococcus (GBS)

HSIB found that mothers carrying Group B streptococcus (commonly known as group B strep or GBS) are not always given the correct amount of information about GBS in childbirth that RCOG recommends. In some cases, this affected their ability to make decisions about taking antibiotics during labour, and when to attend hospital, which was made worse by maternity services encouraging them to stay at home for as long as possible. RCOG guidance recommends that mothers who are known to carry GBS should be seen earlier in labour to allow antibiotics to be given. Positive test results for GBS were not communicated to the mother, or noted clearly in their medical records, depriving them of proper care and antibiotic treatment in labour.

HSIB identified cases where newborn babies with signs of GBS infection suffered severe brain injury or death as a result of failure to identify or treat their infection.

Theme 8 - Cultural considerations

In keeping with maternity safety reports from MBRRACE and CQC, HSIB found that the disproportionately high maternal death rates of women from black and Asian ethnic backgrounds, arises from misunderstanding and miscommunication problems which go beyond mere language differences.

Factors contributing to multi-cultural maternal mortality (death) included:

• translation services not being used by maternity staff;
• family members or staff being used as interpreters, leading to misunderstandings;
• incorrect assumptions that mothers who speak ‘good English’ understand the advice they are being given about their maternity care;
• women from different backgrounds having different expectations about what they are expected to do, the support that is available to them and how to access it;
• women from different backgrounds feeling unable to challenge or question their care.

HSIB’s National Maternity Safety Report says too little, too late

For an organisation that has had exclusive access to confidential investigations behind over 1,000 incidents involving stillbirth, neonatal death and brain injury to babies and maternal deaths potentially caused by mistakes in maternity care since April 2018, HSIB’s first national safety report says far too little, too late. 

At least seven of the eight themes identified in HSIB’s first national maternity safety report at best reflect, but add nothing to, the repeated findings of other maternity safety reports from RCOG’s Each Baby Counts, CQC and MBRRACE. We already know, from these reports and our own client families’ experiences, that closed, ineffective leadership and management practises, inadequate risk management, poor communication, teamwork, training and skills, such as in CTG/fetal heart monitoring, remain system-wide threats to the safety of mothers and babies during maternity and neonatal care.

As yet another organisation reports on this, arguably with more inside knowledge than any other to date, what is missing is evidence of any practical impact from what has been learned and a consequent reduction in harm. HSIB’s report makes no recommendations and its detailed comments on all themes are deferred to further reports which we are told to expect later in 2020 or 2021, by which time HSIB will no longer bear responsibility for maternity safety investigations. 

Amongst its many stated values, HSIB claims to value transparency, objectivity, expertise and learning for improvement, and maintains that it works closely with patients and their families and healthcare staff affected by patient safety incidents, but sadly falls far short, both in our clients’ experiences of delay and lack of communication and this report. Once again, those most severely harmed by negligent maternity practises have been given too little, too late.

If you are caring for a child with cerebral palsy or severe neurological disability or have been affected by maternal obstetric injury or death and would like to find out more about making a claim, contact us by email at cerebralpalsy@boyesturner.com.