New maternity warning system "could have stopped Leeds tragedies," NHS says
A new maternity safety alert could have prevented tragedies involving mums and babies in Leeds, the NHS has said.
The new warning system, rolled out this week, will analyse data being routinely recorded by maternity teams on wards to spot whether there are potential emerging safety issues which need urgent attention and action.
If the system detects a pattern or trend in the data which seems out of the ordinary, it will send out a warning signal indicating a safety check should be urgently carried out on that unit within eight days.
Once a signal is generated, it is mandatory for the maternity unit to carry out a critical safety check within eight working days and share action taken with regional and national teams.
Signals will be traffic-light coded, with amber alerts representing a 95 per cent confidence and red alerts, a 99 per cent confidence that the increase in events is real and needs urgent attention.
The robust online system, named the Maternity Outcomes Signal System (MOSS) is now being rolled out across all maternity services in the country, seven days a week.
Retrospective analysis shows MOSS would have detected signals in maternity units that later experienced serious incidents, including East Kent, Shrewsbury & Telford, Leeds, and Nottingham.
Duncan Burton, Chief Nursing Officer for England, said: “There have been too many times where safety issues in maternity could have been detected earlier, and we have seen the devastating impact this has had on families.
“Having a signalling system for maternity which can carefully look at data in near real-time and spot early warning signs if something is potentially going wrong will help to avert safety incidents and prevent tragedies.
“It is the first national system of its kind in maternity to be able to signal potential safety issues as they emerge and allow them to be acted on faster by maternity services.
“And it will be the responsibility of staff in maternity services and hospital’s board executives to urgently act on warning signals so problems can’t be ignored or delayed.”
The new system comes weeks after Health Secretary Wes Streeting bowed to pressure to launch an independent inquiry into maternity services run by Leeds Teaching Hospitals.
Investigations have found more than 70 families have been affected by poor care at the Trust.
Mr Streeting said he was “shocked” by their experiences of “repeated maternity failures in Leeds – made worse by the unacceptable response of the trust”.
Despite running one of the largest teaching hospitals in Europe, “it remains an outlier on perinatal mortality,” according to official data.
Speaking at the time the inquiry was launched, Mr Streeting added: “This stark contradiction between scale and safety standards is precisely why I’m taking this exceptional step to order an urgent inquiry in Leeds.
“We have to give the families the honesty and accountability they deserve and end the normalisation of deaths of women and babies in maternity units.
“These are people who, at a moment of great vulnerability, placed their lives and the lives of their unborn children in the hands of others – and instead of being supported and cared for, found themselves victims.”