Two important reports were published on 10 December 2020 that outline the next steps for meaningful improvement in maternity services and perinatal mortality reviews.
The second annual report of the National Perinatal Mortality Review Tool, Learning from Standardised Reviews When Babies Die and the emerging findings and recommendations from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust (The Ockenden Report) both, rightly, recognise the importance of acknowledging the needs of bereaved parents and families and ensuring these are the centre of reviews and next steps.
The National Perinatal Mortality Review Tool recognises that the review of care when a baby dies should be universally regarded as part of routine maternity and neonatal care, and that such a process must be resourced appropriately, involving multidisciplinary teams. Investment must be prioritised to deliver targeted improvements in the service and improved engagement is required with parents.
The Ockenden Report recommends strengthening partnerships across neighbouring Trusts and local networks, as well as developing robust pathways for identifying risk and managing complex pregnancies.
Dr Jean MacLeod, Director of Quality Research and Standards at the Royal College of Physicians of Edinburgh, said:
It is vital that the medical community learns from these reports. Both highlight the need to respect bereaved families and the grief that they have experienced, as well as the importance of listening to their voice in making meaningful improvements in maternity services that could save the lives of future new-borns and mothers.
It is important, too, that openness, honesty and timeliness are guiding principles in investigations of this type.
The College recognises, as highlighted in the reports, the need for co-ordinated care in high risk pregnancies within multi-disciplinary teams to ensure patient safety and quality care outcomes.
We note a growing prevalence of high-risk pregnancies, including patients presenting with underlying medical concerns, particularly obesity and diabetes. We now see other patients with complex medical histories including transplantation, cardiac disease or surgery, and cancer survivorship. Acute situations developing in pregnancy is also a key consideration. Physicians must be able to work closely with obstetric colleagues in helping these women to have quality care.
The College is committed to undertaking further work in this area, informed by our maternal medicine conferences and addressing the training needs of Fellows and Members. We anticipate that these reports will provide a key focus in future clinical discussions and debates around patient safety and improvements in maternity services.
