A new warning system designed to stop babies and mothers suffering preventable deaths or injuries is being rolled out by NHS England.
The first-of-its-kind safety system will constantly track how many babies and mothers die and are seriously harmed at every NHS maternity ward in England.
This data will be compared in real time with statistics gathered at other NHS hospital trusts across the country so the system can ascertain the likelihood that these outcomes were due to poor care at that particular ward rather than chance.
When there is a high (95%) level of statistical confidence that deaths or serious injuries, such as brain damage to a newborn baby during childbirth, have started occurring at least twice as frequently as would normally be expected on a ward that size, the system will alert the ward’s leadership team to carry out critical safety checks within eight working days.
Alerts with very high statistical confidence (99%) will require urgent attention.
Ward managers will be required to review all the care received by the mothers and babies who died or were seriously injured.
The actions that the NHS ward staff take in response to these checks will need to be signed off by the trust’s board executive, including its chief nurse, chief medical officer and executive safety champion, and shared with regional and national NHS teams.
Recent inquiries have found hundreds of women and babies have died or were injured during childbirth due to substandard care at certain NHS maternity units.
East Kent, Shrewsbury & Telford, Leeds and Nottingham NHS trusts have all been rocked by scandals in recent years after reports emerged of appalling failings in their maternity care.
NHS England said retrospective analysis shows the new system, named the Maternity Outcomes Signal System (Moss), would have detected signals of poor care at maternity units that later experienced what it described as “serious incidents”, including East Kent, Shrewsbury & Telford, Leeds and Nottingham.
The health and social care secretary, Wes Streeting, said Moss was “a sophisticated early warning system that will sound the alarm when patterns emerge that need urgent attention”.
He said: “For too long, maternity warning signs have been missed. Now, this is a key step we are taking to improve maternity care.”
The system was developed by NHS England in collaboration with Dr Bill Kirkup, who wrote a scathing report in 2022 on the substandard maternity and neonatal services at East Kent hospital trust after a three-year investigation, and Prof Sir David Spiegelhalter, the renowned statistician who identified that monitoring GP death rates could have detected the murders of the GP Harold Shipman.
Kirkup said: “This is a really positive development that originated directly from the investigation into East Kent maternity services. The families there who did so much to bring this to light deserve great credit for the improvements it will bring.”
Moss was initially tested at Cambridge University hospitals NHS foundation trust and is already in use at 48 maternity units across England.
From today, Moss will also be rolled out to the other 71 maternity units run by the NHS in England to ensure all maternity services in the country are being monitored by the system 24/7.
Streeting added: “We are making sure failures of the past cannot be repeated, and that every mother and baby receives the safe care they deserve.”
