The HSSIB argues that challenges in maternity and neonatal safety are the result of systemic issues at a national level, rather than isolated issues within local areas.
A report from the Health Services Safety Investigations Body (HSSIB) reiterates that challenges in maternity and neonatal safety are the result of systemic issues at a national level, rather than isolated issues within local areas.
Healthcare Today has consistently highlighted the issue of maternity safety such as maternity services at Swansea Bay University Health Board and those at Leeds Teaching Hospitals NHS Trust.
The HSSIB report emphasises the importance of taking a different approach to maternity safety. It has key themes, from the safety concern reports and 17 national stakeholder interviews, that indicate systemic issues need to be addressed to tackle the risks within maternity and neonatal care.
It highlights the fact that national and neonatal maternity systems are overly complex, national collaboration is inconsistent and variable, and that too many recommendations are made at a national level, with limited implementation.
“The report evidences that serious safety concerns continue to exist across maternity services, despite past events. We need to ensure safety concerns are effectively and proactively understood and managed to ensure significant improvements are delivered,” said HSSIB’s director of investigations Philippa Styles.
Failure to learn
The report suggests that there should be a focus on the systems that impact safety rather than a focus on individual actions. It reinforces this through the themes relating to risk and learning within maternity and neonatal services.
As Nina Vegad, director of Investigation Services at TMLEP, wrote last week: “When failures repeat across services for example, maternity, cardiology, orthopaedics, and over multiple years, we are no longer talking about individual lapses. We are confronting systemic weakness.”
This should be what the report calls “an urgent priority for stakeholders”. It highlights examples of where clinical risks relating to labour and birth were not anticipated or responded to. It also mentions the system has not been learning from past events, incidents, litigation or national inquiries in the way that would be expected.
Harm to women and families has been compounded by their treatment after maternity incidents. There is a huge variation in whether women and families feel listened to, the report says, and this variation reflects differences in organisational culture.
“There needs to be more positive support for staff working in maternity and neonatal services,” said Styles. “A culture focused on blame is impacting their wellbeing and their ability to work effectively, but will also stifle progress because they feel fearful to speak up about their concerns. Enabling staff to speak freely, without repercussions, is vital to supporting a positive and collaborative approach to improving maternity safety,” she concluded.
