Investigating safety risks in maternity care

Investigating safety risks in maternity care
© iStock/Ivan-balvan

Lorna Rothery spoke to Dr Lesley Kay, Acting Executive Medical Director of the Healthcare Safety Investigation Branch about how the organisation is working to drive sustainable improvement in patient safety and maternity care.

The UK’s National Health Service is facing the greatest staffing crisis of its time. New research has suggested that NHS England has a shortage of around 12,000 hospital doctors and over 50,000 nurses and midwives which is directly impacting mounting workforce pressures and its ability to suitably meet the demands of routine services, emergency and maternity care. Thinly spread resources across healthcare not only pose a risk to staff safety and wellbeing but the quality-of-care patients receive.

The risk to patient safety has been sharply felt across many areas of care, particularly in maternity care where over 500 midwives left their roles within a single year. Evaluating patient safety incidents in maternity care form part of the remit of the Healthcare Safety Investigation Branch (HSIB), a world-first organisation aiming to understand the factors that led, or could lead, to patient harm and equally, how care delivery could be improved. The multidisciplinary organisation carries out safety investigations across NHS-funded healthcare and NHS maternity care while advocating a no-blame culture.

Lorna Rothery spoke to the organisation’s Acting Executive Medical Director, Dr Lesley Kay, about the HSIB’s approach to assessing patient safety risks, its role in influencing systemic change, and how the imminent organisational transition to becoming the Health Services Safety Investigations Body (HSSIB) will broaden its remit across NHS-funded and privately funded healthcare.

To begin, can you tell me about the HSIB’s approach to assessing safety risks in healthcare?

We address risk slightly differently in healthcare compared to many of the safety-critical industries. Our approach is to look at safety from a systems viewpoint and we rank interventions hierarchically and consider which measures will make the biggest difference. For instance, we know PPE is a barrier to infection for individuals, but much more effective barriers would be to stop areas having a high threat of viral infection transmission in the first place. Likewise, lots of hospitals are designed so that you cannot open windows for safety, or for air conditioning so this means we need to think about the levels of intervention and control.

Other safety-critical industries work within a safety management system. The safety management system is a structured approach to safety using proactive measures whereby you assess what your risks are, and have structures in place to monitor, prospectively, whether you are addressing those risks and whether your interventions are likely to mitigate those risks.

The safety management system is not a structure that we have adopted universally in healthcare but our ‘Never events’ report looks at the potential of this approach. It is something we will be addressing as part of subsequent reports to think about how healthcare could have a more proactive and systematic approach to safety rather than being reactive or considering different risks in isolation.

What key steps could have been taken in the early stages of the COVID-19 pandemic to reduce patient safety risks in maternity care?

We have five reports that are relevant to this including one which looked at maternal deaths, and another which looked at intrapartum stillbirths in the early part of the pandemic. We all appreciate the context of those early months of the pandemic when COVID was still very much an unknown condition, for which we did not have any protection in the form of vaccines, and services had to change very quickly.

There are lessons we can take from those reports; for instance, when women had to come to the hospital alone, and barriers to communication if English was not their first language. The pandemic impacted women’s behaviour towards hospital care, and we found that some women were self-discharging or choosing not to come to the hospital at all. We try very hard not to look at hindsight at HSIB, but those were certainly challenges that nobody had any experience with nor were they able to predict some of those behaviours.

There was a big shift in the relationship between provider and patient due to the increasing reliance on remote consultations, and this had some unintended consequences. However, even though this approach was new to a lot of staff, I think they acquired more skills in remote care during the pandemic as a result.

One of the main findings from our investigation into the NHS 111 response was that the contracts that were stood up about making changes were largely based on the influenza pandemic; that will be addressed in the public inquiry and whether they could have drawn more on the trial exercise for the SARS-CoV-2 based provisions. What we found that I do not think anybody else had seen until then, was the fact that the contracts were not delivered as intended. The expectation was that all these calls would be filtered through to one service, but that service was not able to accommodate all the provisions of the contract from the beginning, particularly recording calls. That led to some unanticipated problems. We make recommendations in that report around being able to follow through on contracts that you have stood up in an emergency. Those are useful lessons that will no doubt come through in the public inquiry, which we can learn from.

Our investigation into oxygen issues during the pandemic really showed the unprecedented demand for oxygen supplies in hospitals, and that our estate, in terms of oxygen delivery, was not ready for that. We recommended that the parts of a hospital service that manage the estates, and those in incident planning should be brought together earlier. For example, in the context of infectious disease, it makes total sense to cluster patients with that condition, but then you are putting a huge demand on the oxygen flow to that ward. We had photographs of frozen pipes from this massive increase in oxygen flow so there is something structurally around hospitals that we have picked up.

Our reports show the value of the HSIB in that we have a very multidisciplinary investigation workforce, which includes engineers, and it was our engineers that went out primarily to look at the oxygen on an urgent basis.

Are the support systems in place for healthcare workers sufficient to enable them to deliver care safely?

In his book, Zero former health secretary Jeremy Hunt shares how he initially thought of healthcare culture as something woolly and nebulous, and then came to realise that it is fundamental to how staff behave, and how organisations treat safety.

The NHS is the biggest employer in the UK and our staff represent a cross-section of society. If you do not have a system in which staff feel they are going to be listened to when they raise concerns, or if they are going to be blamed if things go wrong, then you start seeing defensive practice, you start seeing people not reporting things because they are scared and in that way you cannot learn. That was particularly important during the pandemic where so much was unknown; in our reports, we highlighted the rapidity in which guidelines were changing, even between people’s shifts. One particular example is every time paramedics were starting their shift in an ambulance station, they had to look at the guidelines on a notice board because they would have changed since their last shift. In that situation, you need to be able to rely on your staff to adapt, react and feedback when things appear unsafe or are new. That culture is critical; we know from NHS staff surveys that we are not there yet.

I do not think there is a leader in healthcare who does not talk about no blame culture and restorative justice being really important, yet we see in staff surveys that there is no real improvement on the ground.

The HSIB absolutely operates in a no-blame way. In many of our investigations, staff say to us that we are the first people who have listened to their account of what happened. We have seen staff be harmed by the process of firstly, the error and in general, people in healthcare are extremely conscientious and feel this sense of moral injury when they did not deliver the standard of care they wanted to.

The main learnings from our report on staff involved in safety incidents were making sure staff were involved in the investigations and that there is a system focus in that investigation. Root cause analysis is a traditional method used in healthcare and yet root cause analysis is designed to find out individual actions that went wrong. In our training programme, we have a module for senior decision makers to try and help them understand what a good systems safety investigation looks like. It does have an emphasis on no blame, and if your findings mean individual staff need to be retrained or disciplined or a policy needs to be rewritten, then it is unlikely that you have appreciated all the system-level measures that are more likely to be effective. If you want to make changes and improve safety, you need to start with a system-level approach.

In our interim bulletin about delays in the transfer of care, the two primary investigators who went out were not from clinical backgrounds. They were shocked by how much staff were harmed by not being able to deliver the care they wanted. I suspect if it had been some of our clinical investigators going out, they would not have had the same reaction. We are putting healthcare staff in terrible positions, through the pandemic and during what we are optimistically calling recovery.

© iStock/SDI Productions
The NHS is the biggest employer in the UK and our staff represent a cross-section of society. If you do not have a system in which staff feel they are going to be listened to when they raise concerns, or if they are going to be blamed if things go wrong, then you start seeing defensive practice.

What key risks do staff shortages pose to patient safety? How does the HSIB plan to use the Special Health Authority to influence systemic change and improve the safety of maternity care?

The maternity programme is still quite a young programme; we just reached full coverage around the time before the pandemic, and we have done over 2,000 individual maternity care reports so far. They are not published; the recommendations are local recommendations that go back to the trust, but we are increasingly trying to learn lessons from those reports and aggregate them thematically. We are just about to publish this year’s annual report and we have pulled out themes including maternal deaths and intrapartum stillbirths in early COVID.

Staffing is a particular issue that is very well known in maternity care and is true right across the board, in health and in other industries. Staff shortages directly impact continuity of care, which I think the Ockenden review has highlighted. The ability to have the fresh eyes approach, to have somebody else look at how labour is progressing or to keep a helicopter view of what is happening on a labour suite becomes more difficult when people are understaffing pressures. If you are short-staffed it is easy for people to be dragged into other operational clinical work instead of keeping an overview of procedures, which is critical for safety.

On an individual level, we know that mistakes are more common when people are working under immense pressure and are unable to spend that time with patients and listen to them. It is a very uncomfortable fact, but safety is totally dependent on people. The concept of safety is that more things go right because people anticipate errors and can pull things back from the brink of disaster. However, if staff are exhausted, thin on the ground, or harmed by what has happened, it is much more difficult for them to get those basic things right. As a patient on the receiving end, it is you that sustains the impact of that shortage of staff. One of the reasons we are seeing so much burnout and early retirement of staff is because of that awareness that they are more likely to make mistakes.

I hope that the plans to address staffing, the plans to streamline how we work and the Ockenden report recommendations will improve safety and the awareness of what it means to be short of staff or where errors are likely to happen. These factors must be managed proactively. Where we come in is pointing out common themes; we circulate a newsletter where we show how trusts have learned from the recommendations that we have made and share examples of good practice. Flagging up where people have been able to improve means that people can understand how it applies to their situation and what they can do. We try to highlight good practice and where things have gone right.

How will the organisational transition to becoming the Health Services Safety Investigations Body (HSSIB) impact your overall remit within the healthcare sector? What opportunities will this present for whole system learning?

We are separating into two organisations, so the maternity care programme goes into a special health authority and as we understand it, it is likely to continue to function in a very similar way.

It is an exciting time for us, we have been waiting for this legislation since the organisation started. The only similar body to us in the world is the Norwegian Ukom and they had their legislation first, and then set up their processes and procedures. One of the biggest changes regarding our remit is we will have to reach into non-NHS-funded care as well as NHS-funded care; at the moment, we are trying to flesh out exactly what that means for us. You think about private providers but then you start thinking about what the definitions of healthcare are. How far does this go into high street-provided healthcare, for instance?

We have done one investigation so far that is published and looks at the private provision of NHS-funded care and some of the disjuncture between NHS care and care in the private sector. We have had a really good response from private sector providers who are very keen to work with us and very keen to ensure that the recommendations are implemented and that care is improved.

One of the advantages of our work is that we can look across pathways of care and we have already done this within the NHS but will be able to extend that into the private sector as well. I think this chimes very well with the introduction of ICSs and ICBs, healthcare is going to shift to being more pathway-focused.

We will have different powers as we move into being HSSIB. One is that we will be able to access healthcare records, the environment, and can speak to staff without consent. We often experience significant delays in getting consent from patients and families to access records, we will not need to have that consent in the future. Similarly, we sometimes have difficulty engaging with staff who have not understood our remit or come across us before. It can be quite a lengthy process negotiating with people to be interviewed but we will be able to require them to speak to us in future; we hope never to have to use that power but rely on persuasion. We want to be very clear when communicating who we are and what we are here for, that we are not able to apportion blame on individuals, and that we are here to look at the system. We are working on making our materials very clear for that; but the underlying thing in those is staff have no choice, they would have a duty to speak to us. In some ways, that will protect staff as sometimes, it is not them but their line manager or employer who is anxious about speaking to us.

To balance that, we will have a legally protected, safe space for interviews and those materials, and we can be prosecuted if we release them without good due process. Those records are also protected from anybody, including the coroner and the ombudsman unless they go to a high court to get a decision made on that. I think that balances well, a compulsion of someone to speak to us versus knowing they have confidence that those interviews or materials are very highly protected. In some ways, it will streamline what we are doing at the moment, but it is incumbent on us to communicate really well to people what we are here for and what we are doing.

© iStock/sturti
We want to be very clear when communicating who we are and what we are here for, that we are not able to apportion blame on individuals, and that we are here to look at the system.

How important is collaboration between services and organisations in addressing patient safety issues? How could greater collaboration and joint working enhance system-wide learning?

The maternity care landscape is very crowded, there is the Ockenden review as previously mentioned, MBRRACE-UK which looks quantitatively at patient safety in a similar area, and the UK Government’s Maternity Disparities Taskforce. We work closely with all of these organisations and one of the questions we always ask ourselves is: ‘what are we adding to the picture?’ We may well not choose to do an investigation because there is already a public inquiry going on. For example, in the Cumberlege review, we knew they were looking at sodium valproate risk and it was being exhaustively reviewed so although we had cases referred to us, we did not take them on because we have a limited number of investigations we can do a year.

Our independence is absolutely critical to our credibility; families and staff need to know that we are not being controlled or interfered with and that we are truly coming at this as an independent investigator. We have to balance that with collaborating with the system to make sure that our recommendations have an impact, and that we are working in the same direction as others. The collaboration has to be there to maximise efficacy, and though we have been told that we make too much of our independence, I do not think you would hear that from a member of staff or family that we interviewed. We are reviewing exactly what collaboration means to us and the two new organisations.

We are collaborating very well with the Norwegian branch and had a face-to-face meeting with them in May. We are finding what we can learn from each other as well as other bodies such as transport and defence. To have another organisation that does things in quite a different way, but is facing the same issues as us, is a very good relationship to have.

The HSIB has been in existence for five years, we have a critical mass of work now and I think changing into the two new bodies has given us a real opportunity to review every aspect of the way we work, to make sure that we have learned everything we can and that we are as effective as we can be.

Dr Lesley Kay
Acting Executive Medical Director
Healthcare Safety Investigation Branch (HSIB)

This article is from issue 23 of Health Europa Quarterly. Click here to get your free subscription today.

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