Learning from maternal deaths during the pandemic

The lessons that can be drawn from the Healthcare Safety Investigation Branch's (HSIB) report on maternal deaths.

The Healthcare Safety Investigation Branch (HSIB) has been operational since April 2017. It undertakes independent investigations across the NHS in England with the aim of improving the provision of healthcare at the system level. Since its conception, one area the HSIB has focused on is maternity investigations.

Investigation reports including safety recommendations are published on the HSIB website, the purpose of which is to promote learning and improvement and not to attribute blame or liability. It’s not a regulator and isn’t responsible for assessing professional practice. While the HSIB is funded by the Department of Health and Social Care, it operates independently from it and from the CQC.

In 2018, the HSIB became responsible for conducting all maternity safety investigations in the NHS which meet the criteria under The Royal College of Obstetricians and Gynaecologists’ (RCOG) Each Baby Counts programme or the HSIB’s own criteria for maternal deaths, with the aim of achieving rapid learning across maternity services. Its latest report regarding maternal deaths was published in February 2021 and focused on deaths which occurred during the first peak of the COVID-19 pandemic in England, between 1 March 2020 and 31 May 2020. The issues raised by the investigation are, however, applicable to all services and the recommendations can help improve systems generally to optimise patient safety.

Seven themes were identified from the HSIB’s analysis:

Unprecedented demand for telephone health advice caused delays in accessing health care.

This included attempted contacts with NHS 111, GPs and maternity services. There were significant delays, families making repeated attempts and abandoned calls. The investigation found that, out of the 20 deaths reported, three women had died at home. There was an impact on family members who were required to assist healthcare professionals at home including with resuscitation and the use of equipment.

Public messaging and ‘safety netting’ advice caused delays in seeking healthcare.

Women were put off attending hospital for longer than they would otherwise have done due to the government’s message to ‘Stay Home. Protect the NHS. Save Lives’, the risk of COVID-19 and due to having to attend hospital without the usual support from their partner or family. Women were often advised to stay at home in accordance with the national guidance, including those with a fever and/or cough.

In some cases, there was no evidence of clear individualised advice about when to return and no tailored safety netting advice. COVID-19 was listed on the medical certificate of cause of death (MCCD) for six women.

Guidance changed rapidly.

As in many areas, guidance changed quickly making it difficult for trusts and staff to stay up to date. This led to inconsistency with some trusts allowing partners or family members to attend while others did not. PHE guidance on infection control and prevention was updated 21 times by the end of May 2020 and PPE advice was updated six times.

Problems arose due to the lack of a formal local dissemination process of information to staff. In some trusts, primary care and emergency services found it difficult to manage the amount of updated guidance from different specialities. Local guidance also sometimes contradicted national specialty guidance.

Use of early warning scores did not always detect deterioration.

Local guidance did not prompt escalation because the NEWS 2 score which is used across healthcare services was not designed for use in pregnant women. It was noted that there are no nationally agreed maternity specific early warning systems in England. However, NHS England and NHS Improvement’s maternity and neonatal safety improvement programme (MatNeoSIP) has been tasked with producing an evidence based, standardised obstetric early warning scoring system.

Personal protective equipment requirements changed due to COVID-19.

The time taken to don and doff PPE led to delays in commencing Category 1 caesarean sections. As in other areas of healthcare, communication was made difficult for staff and patients due to PPE, particularly in noisy environments, causing voices to be muffled. This also led to raised stress levels in staff.

In addition to this, the HSIB investigation identified other difficulties created by the use of PPE, such as, face coverings restricting the healthcare worker’s field of vision, particularly when looking down which resulted in the need to adjust face coverings and therefore increasing the risk of contamination.

Staff described feelings of stress and distress which can affect performance.

As well as difficulties created by the wearing of PPE, staff experienced raised stress levels due to redeployment to unfamiliar work areas and due to staff shortages. The effects of increased stress was noted in the HSIB’s investigation report and the impact this has on patient safety. The need for more organisational resilience was also noted.

Difficulties in making a diagnosis and choosing treatment strategies.

Local policies recommended a reduction in hospital and home visits including those with community midwives and health visitors. This meant the usual observations taken during pregnancy were done less frequently. Communication difficulties including reduced face to face assessments and reduced access to tests that would normally have been performed led to difficulties in diagnosis and treatment. Like in other healthcare settings, risks and benefits had to be balanced. This was made more challenging in maternity services due to the complexity of a new disease and physiology in pregnancy.

As a result of the investigation, the HSIB made three safety observations:

  • "It may be beneficial if further work is done to understand the increased risk of maternal death for women from Black, Asian and minority ethnic backgrounds and those with higher socio-economic deprivation.
  • It may be beneficial if the NHS England and NHS Improvement communications toolkit for local maternity teams to improve communications with women from Black, Asian and minority ethnic backgrounds is implemented in all healthcare services for pregnant women.
  • It may be beneficial if written safety netting advice is developed for pregnant and postpartum women about COVID-19 and other common conditions, incorporating MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) recommendations."

As part of their investigation into a clinical incident the HSIB interviewed healthcare professionals who have been involved in the care of the patient. It is important to bear in mind the emphasis of an investigation is to learn from the event and share any learning across the healthcare system, rather than to apportion blame.

The MDU is on hand to support doctors called upon to provide information to the HSIB. We suggest members contact us before attending the interview so that we can provide specifically tailored advice and support.

For a more in-depth introduction to the HSIB, you can read an interview with its chief investigator in a recent issue of the MDU journal.

This page was correct at publication on 12/04/2021. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.


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