Patient Safety Watch: Maternity safety stays in the spotlight

Good afternoon, and welcome to this fortnight’s Patient Safety Watch newsletter, starting as we so often do with maternity safety developments and updates.

New clinical standards launched to reduce maternal deaths

Firstly, some welcome news, with NHS England announcing new clinical standards for maternity services to help reduce maternal deaths.

These focus on earlier risk identification and better access to specialist care, targeting maternal mortality’s main causes, such as blood clots, strokes, cardiac disease, suicide, sepsis, haemorrhage, and pre-eclampsia.

All pregnant women will get a venous thromboembolism early assessment, with higher-risk patients offered preventive treatment within 72 hours.

Women with epilepsy will have access to specialist teams and tailored care plans. Mental health assessments will be standardised, with clearer referral routes, and new escalation thresholds aim to speed up senior clinical input for haemorrhage.

The announcement also sits alongside the Maternal Outcomes Signal System (MOSS) rollout, designed to spot emerging safety concerns in maternity services, and developed in response to the East Kent report.

Kate Brintworth, chief midwifery officer for England, said: “We still see symptoms of serious medical problems being missed, especially for Black and Asian women. By setting out these clinical standards and holding hospitals to account, we can significantly reduce avoidable deaths and prevent future tragedies.”

Stillbirths review at Sandwell trust amid concerns over investigations

Sandwell and West Birmingham Trust will review all stillbirths from 2025, examining both care provided and the quality of internal investigations using the national perinatal mortality review tool (PMRT) process.

As reported by HSJ, a Care Quality Commission inspection earlier this year raised concerns about the trust’s PMRT process. In 19 stillbirth cases it examined, “none… had issues with care that was likely to have made a difference to the outcome”, despite evidence of missed diagnoses, monitoring failures, and poor communication.

Families have also raised concerns about transparency and involvement. Tom Hender, whose son Aubrey was stillborn at the trust, said the PMRT reviews were the “only form of investigation open to many parents”, and the CQC’s findings “potentially show that they’re not investigating properly”. He also questioned why the review is limited to 2025.

The review is due to finish by July.

My view? Since 2015’s Morecambe Bay Investigation, maternity services have repeatedly been criticised for poor-quality investigations, limited learning, and compounded harm for bereaved families seeking answers after tragic outcomes. Open, transparent, independent, and robust reviews of every case where there is potential learning should not be something families have to fight for; they should be assured.

The Amos investigation and the national taskforce must fix this, once and for all.

NHSE home birth proposals raise safety and rights concerns

As reported by HSJ, NHSE is considering guidance that could allow midwives to “withdraw” services from women choosing home birth against clinical advice.

The proposals follow a coroner’s report and could apply more widely to care deemed “highly unsafe or unreasonable”. Critics warn the move could increase “freebirths”, where women give birth without professional support.

The Royal College of Midwives said withdrawing care could push women to give birth alone, increasing risk to mother and baby. Charity Birthrights described the approach as a potential “erosion of human rights by stealth”.

In other news, this edition…

Patients to remain in unsafe hospital for two more months

As reported by HSJ, NHSE has set an end-of-June deadline to move the “majority” of high-risk patients out of St Andrew’s Hospital, Northampton.

This follows earlier NHSE instructions six weeks ago to relocate nearly 300 patients. Priority groups include forensic patients who either do not originate from the Midlands or are in nationally commissioned services, patients in a non-specialised commissioning bed, and those deemed clinically ready for discharge.

The hospital has been barred from admitting new patients since last summer, after a CQC “inadequate” rating, and is now subject to three ongoing police investigations into abuse and neglect allegations.

Safety concerns over nurses covering doctor rota gaps

A Guardian report highlights hospitals using advanced practitioners (APs) – often senior nurses – to fill doctor rota gaps, raising patient safety concerns.

British Medical Association figures suggest nearly half of hospital trusts deploy APs in roles traditionally done by doctors, including accident and emergency, critical care, and neonatal units.

NHSE said APs “are highly skilled practitioners and are valued members of NHS teams alongside doctors. These roles should not replace the role of doctors and should only be used in line with their competence and qualifications”.

HSSIB report highlights pressures in community mental health care

The Health Services Safety Investigations Body has published a new report setting out learning from a case involving a man who attempted suicide while under community mental health services care.

The report highlighted issues with poor information sharing between services, delayed identification of reasonable adjustments to support engagement, uncertainty around prescribing when alcohol or drug use is present, and pressure on overstretched community teams.

HSSIB also noted staff were affected emotionally and did not always have protected time or support after distressing incidents.

‘I nearly died because it was a Saturday’

The Birth Trauma Association have shared a powerful story from Katie, whose experience of multiple postpartum haemorrhages highlights the impact of variations in maternity care.

After being readmitted with severe bleeding, delays in weekend ultrasound access meant a retained placenta went unnoticed for days, contributing to further haemorrhage and emergency surgery.

Katie lost several litres of blood and required multiple transfusions. She reflects: “I nearly died because it was a Saturday.”

A stark reminder that consistent, seven-day access to diagnostics and specialist care is essential for maternity safety – hopefully an area Baroness Amos and her team are examining closely.

Oliver’s Law: A campaign for safer medical cannabis prescribing

A campaign is calling for tighter safeguards around medical cannabis prescribing, particularly for patients with serious mental illness. Led by Xander Robinson, following his brother Oliver’s death, the campaign argues that regulatory gaps put vulnerable patients at risk.

Sharing some good stuff…

UK MUM Awards 2026

Baby Lifeline has launched the UK MUM (Maternity Unit Marvels) Awards 2026, aimed at recognising individuals and teams delivering exceptional maternity and neonatal care across the UK.

Every day, healthcare professionals make life-changing decisions to keep mothers and babies safe. These awards shine a light on the people behind those moments, celebrating outstanding care, compassion, and dedication through the voices of the families and colleagues they support.

Global Patient Safety Awards – applications open

Applications are now open for the Joint Commission International Global Patient Safety Awards, recognising innovative, real-world solutions that improve patient safety.

Run by JCl, the awards are open to healthcare organisations and system leaders worldwide, with a focus on impact, innovation, and scalability.

That’s all for this edition. Before signing off, a quick thank you to everyone who supported Jeremy and me in running last weekend’s London Marathon. It was my first marathon, and although I didn’t set any records, it was an unforgettable experience. A big thank you to everyone who helped me raise more than £1,600 for Baby Lifeline – it really will make a difference.

Huge congratulations to Jeremy, who, despite running some of the race wearing a large plastic bone, still finished well ahead of me!

Thanks for reading, and please look out for the next newsletter from Jeremy in a fortnight.

James