References

Baby Lifeline. Mind the Gap: An Investigation into Maternity Training for Frontline Professionals Across the UK. 2018. https://babylifeline.org.uk/home/wp-content/uploads/2014/07/Mind-the-Gap-2018-Investigation-into-Maternity-Training-Final-ELECTRONIC-VERSION-Final-v3.pdf (accessed 18 August 2020)

Shropshire baby deaths: Maternity review expanded. 2020. https://www.bbc.co.uk/news/uk-england-shropshire-53484005 (accessed 21 July 2020)

Care Quality Commission. Getting safer faster: key areas for improvement in maternity services. 2020. https://www.cqc.org.uk/publications/themed-work/getting-safer-faster-key-areas-improvement-maternity-services (accessed 18 August 2020)

Better Births. Improving outcomes of maternity services in England. A Five Year forward view for maternity care. 2016. https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf (accessed 18 August 2020)

Department of Health. Safer maternity care - the national maternity safer strategy - progress an next steps. 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/662969/Safer_maternity_care_-_progress_and_next_steps.pdf (accessed 18 August 2020)

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Each Baby Counts: 2018 Progress Report.London: Royal College of Obstetricians and Gynaecologists; 2018

Tools for frontline professionals

02 September 2020
3 min read
Volume 28 · Issue 9

Abstract

Healthcare organisations need to improve the way they respond and learn following patient safety incidents. Baby Lifeline has developed a course aimed at maternity services to achieve this goal

The way in which healthcare organisations respond and learn following patient safety incidents has been repeatedly highlighted as a cause for concern. Getting that right has never been as important as it is at the time of a national pandemic. Where things have had to adapt and change rapidly, new and unforeseen problems can arise.

In addition, ‘maternity scandals’ are increasingly being reported, where thousands of families have been impacted by substandard care, leading to tragic and life-changing outcomes (Buchanan, 2020; Ng, 2020). It comes as no surprise that a ‘focus on learning and best practice’ is listed as one of the five key drivers for delivering safer maternity care as part of the national maternity safety ambition and action plan (Department of Health, 2017). Learning from investigations and learning from best practice were cited as components leading to better care. In the Morecambe Bay Investigation, Dr Kirkup CBE reported ‘missed opportunities’, where future harm could have been prevented if good investigations, learning lessons, and positive action had taken place (Kirkup, 2015).

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