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safer maternity care: a new approach to learning from harm

4 December 2017

On 28 November 2017, the government announced its refreshed maternity safety strategy to prevent avoidable serious incidents in maternity services. The strategy outlines a number of proposals, including a focus on improving the quality of investigations. From April 2018, investigations which meet the eligibility criteria of the Royal College of Obstetricians’ (RCOG) Each Baby Counts (EBC) programme will no longer be undertaken by NHS Trusts but referred to the Healthcare Safety Investigation Branch (HSIB) to investigate independently, using a standardised methodology, to provide families with a full account of what happened in an individual case and extract learning which can be shared across the NHS. The proposals follow recommendations contained within the Kirkup Report and, more recently, the EBC 2015 Report, (published in October 2017) and NHS Resolution’s thematic review ‘Five years of cerebral palsy claims’, both of which also identified shortcomings in the quality of maternity incident investigations.

The government is also considering a change in the law to enable coroners to investigate the full term stillbirths. At present, coroners can only investigate the deaths of term babies who show signs of life after being born and there are some concerns that these cases are not investigated properly resulting in a missed opportunity for valuable learning to reduce the incident rate of stillbirth in the UK.

NHS Resolution has its own strategic direction, namely to move ‘upstream’ and become involved closer to the point of incident. The Early Notification scheme (EN) is a critical part of this and Trusts should continue to report all maternity incidents likely to result in severe brain injury to NHS Resolution within 30 days. From April 2018, these incidents will be reported to NHS Resolution under the EN scheme and HSIB to understand how and why the incident occurred and, where appropriate, also investigate liability in order to facilitate an early resolution. In this respect, the government has also announced plans to develop the Rapid Redress and Resolution compensation scheme, although we will have to await the details of this scheme, which is not likely to be implemented until 2019.

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