Learning points for maternity units from latest HSIB investigation into delays to intervention

Investigation into delays to intrapartum intervention once fetal compromise is suspected


A Blog by James Titcombe – Senior Patient Safety and Policy Consultant

From 1 April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for all NHS patient safety investigations of maternity incidents which meet criteria for the Each Baby Counts programme (Royal College of Obstetricians and Gynaecologists, 2015) and also maternal deaths. The aim of the programme is to achieve learning and improvement in maternity services, and to identify common themes that offer opportunity for systemwide change.

To date, HSIB have published a number of learning reports:

  1. Summary report of themes arising from the HSIB maternity programme.
  2. Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection.
  3. Neonatal collapse alongside skin to skin contact.
  4. Maternal death national learning report.


This week, HSIB have published a new learning report looking a delays in intrapartum intervention once fetal compromise is suspected.

As with all opportunities to learn from harm, Baby Lifeline Training welcomes this latest report by HSIB. In the work we do with healthcare professionals across the country, we know that multi-professional teamwork and psychological safety (a culture that prevails where staff feel confident, empowered and safe to challenge concerns and talk openly about error) are crucial elements of safe maternity care.

This report again highlights the crucial role that high quality multi-professional training has in supporting safe, resilient maternity systems.

In this blog we will set out key factors observed by HSIB that contribute to improved safety, and also some safety and risk assessments for your own maternity unit outlined by HSIB.


A Pattern of Delay

Delays to intrapartum intervention once there was suspected fetal compromise was identified as a factor in 43 of 289 HSIB maternity investigations undertaken so far.

These findings are consistent with other national reports.

  • The Each Baby Counts reports by the Royal College of Obstetricians and Gynaecologists (2017) found that ‘delay in management of delivery’ was a critical contributory factor in 42% of cases investigated.
  • The 2017 MBRRACE-UK perinatal confidential enquiry into term, singleton, intrapartum stillbirth and intrapartum-related neonatal death found there was a significant delay in both the decision to expedite the birth and in actually achieving birth in approximately a third of the deaths reviewed (MBRRACEUK, 2017).

The HSIB review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. The RCOG and MBRRACE-UK reports also cite influences such as loss of situation awareness, the importance of teamworking and multi-professional training.


Features Observed which Contribute to Improved Safety

The report makes a number of observations and describes the features that contribute to improved safety. The investigation looked at safety risk in terms of organisational resilience – the way an organisation responds to changing circumstances.

The observations include:

  • Regular multidisciplinary ward rounds enable staff to monitor, anticipate and respond in a timely way to emerging problems. They promote a shared knowledge and understanding of the situation (known as a shared mental model). They also provide an opportunity for role-modelling values and standards of practice.
  • Shared situation awareness can be promoted by activities such as safety huddles (short multidisciplinary briefings where staff focus on at-risk patients or potential/existing safety problems) and structured information sharing tools.
  • The benefits of multidisciplinary training, including in-situ simulation have been highlighted in national reports and other studies. Such training supports three of the abilities necessary for resilient performance – response, anticipation and learning.
  • Learning from experience is an important aspect of organisational resilience that requires time and resource.
  • Management of the flow of patients between different parts of the maternity service is critical to resilient performance. Providing senior clinical review at triage assists with flow management by promoting an early and effective response and anticipating future needs.
  • Having a second supernumerary labour ward co-ordinator to oversee elective and emergency workload may, in larger units, reduce delays in response to elective cases and so increase the resilience of the unit.
  • Some physical infrastructure changes; e.g. the use of digital enhanced cordless technology (DECT) telephones and locating consultant offices on or near the labour ward.
  • Teamwork and psychological safety form the bedrock of resilient performance. The significance of these factors has long been recognised and there are ongoing national initiatives directed at assessing and improving teamwork and psychological safety.


Assessing Your Own Maternity Unit

Based on its findings, the HSIB report includes a set of questions that maternity units are asked to consider:

  • Does your unit have a role, or another means, separate from the labour ward co-ordinator, dedicated to monitoring and anticipation of activity across the maternity service and troubleshooting, such as a roving bleep holder?
  • Do you have regular multidisciplinary ward rounds throughout the day?
  • Do you have regular safety huddles and multidisciplinary handovers using a structured information tool?
  • Do you hold multidisciplinary in situ simulation and facilitated debriefing that includes both technical and non-technical skills? Are scenarios and incidents encountered in your unit included in the training?
  • Do you know what your staff’s perceptions of teamwork, psychological safety and communication are within your unit? Are actions taken in response? How are midwifery staff empowered to contact consultants directly if they have concerns?
  • Is time and resource dedicated to regular multidisciplinary forums that provide a safe space to openly discuss scenarios where things did not go well? Do these forums also include discussion and reflection on scenarios where things went well despite unexpected events?
  • Are senior midwifery staff assigned to triage and assessment areas? Is there adequate medical presence in these areas?
  • In larger units, is the workload on the labour ward separated into elective and emergency work? If so, are there separate labour ward co-ordinators for each?
  • How does the physical infrastructure support work? For example, use of DECT telephones, availability of equipment, consultant offices on/near the labour ward, proximity of antenatal ward and neonatal unit to the labour ward.
  • How are issues with staffing and workload escalated and responded to? Are senior trust personnel aware and involved?


National Work to Improve Safety

The report recommends that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multi-professional teamwork and psychological safety in its regulation of maternity units.


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