The Safety of Maternity Services in England.

Book/Report

The Safety of Maternity Services in England.

August 25, 2021

Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Free full text

Related website

Related Resources From the Same Author(s)

Complaints and Raising Concerns.

February 4, 2015

Investigating Clinical Incidents in the NHS.

May 6, 2015

PHSO Review: Quality of NHS Complaints Investigations.

June 22, 2016

Patient Safety.

July 15, 2009

A Safer Place for Patients: Learning to Improve Patient Safety.

July 19, 2006

Good for You, Good for Us, Good for Everybody.

October 6, 2021

Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995.

April 25, 2007

Report of the Independent Inquiry into the Issues Raised by Paterson.

February 19, 2020

The Report of the Morecambe Bay Investigation.

April 29, 2015

Digital Clinical Safety Strategy

October 20, 2021

Learning Not Blaming.

September 9, 2015

Raising and Responding to Concerns.

February 25, 2015

Patient Safety Incident Response Framework.

August 31, 2022

Saying Sorry.

March 26, 2014

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

A Safer Place for Patients: Learning to Improve Patient Safety.

November 16, 2005

Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.

December 4, 2013

The Report of the Short Life Working Group on Reducing Medication-related Harm.

March 28, 2018

Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.

March 11, 2015

Hard Truths: the Journey to Putting Patients First.

November 27, 2013

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

January 19, 2022

An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer.

March 6, 2005

Safety First: One Year On.

January 9, 2008

Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.

July 25, 2018

Solutions from Professional Regulation and Beyond.

October 5, 2022

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

July 1, 2020

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005.

January 2, 2008

A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.

August 21, 2013

State of Healthcare 2008.

November 15, 2008

Safely Home: What Happens When People Leave Hospital Care Settings?

August 26, 2015

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Gosport War Memorial Hospital. The Report of the Gosport Independent Panel.

November 7, 2018

Learning how to learn: compliance with patient safety alerts in the NHS.

August 3, 2005

State of Healthcare 2008.

January 7, 2009

Managing the Costs of Clinical Negligence in Trusts.

October 4, 2017

Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry.

February 20, 2013

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

July 22, 2020

Concurrent and Overlapping Surgeries: Additional Measures Warranted.

January 11, 2017

Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.

March 19, 2014

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

October 24, 2007

A tragic death shows how ERs fail patients who struggle with addiction.

July 28, 2021

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment.

January 10, 2007

Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.

March 13, 2019

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

December 9, 2020

Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

July 20, 2016

VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events.

September 9, 2015

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Patient Safety, Spring 2019 Final CDP Report.

March 25, 2020

Approaches and Challenges to Electronically Matching Patients' Records Across Providers.

March 6, 2019

Patient Options for Safe and Effective Disposal of Unused Opioids.

September 25, 2019

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.

August 15, 2012

Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.

August 7, 2013

Avoiding Unconscious Bias: a Guide for Surgeons.

August 24, 2016

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

May 29, 2019

Learning From Invited Reviews.

April 10, 2019

High Quality Care for All: NHS Next Stage Review Final Report.

July 16, 2008

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Noise: a Flaw in Human Judgement.

August 25, 2021

Learning From Mistakes.

August 31, 2016

Oversight Hearing on Recent Patient Safety Issues.

June 28, 2006

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

November 10, 2021

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

June 16, 2021

Patient Safety in Private Hospitals: the Known and the Unknown Risk.

September 10, 2014

Acting on Concerns: Your Professional Responsibility.

March 6, 2013

Learning from Investigations.

February 20, 2008

Commentary on Sentinel & Serious Events Reported by District Health Boards - 2006/07.

March 5, 2008

Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.

April 2, 2014

Federal speech rulings may embolden health care workers to call out safety issues.

July 21, 2021

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.

December 15, 2021

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Independent Neurology Inquiry.

July 20, 2022

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

January 31, 2006

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

July 12, 2006

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.

July 5, 2006

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Safer Clinical Systems.

May 13, 2015

Medicare cuts payment to 774 hospitals over patient complications.

March 3, 2021

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

May 26, 2021

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns.

December 23, 2020

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans’ Care, but Should Take Action to Ensure That These Data Are Complete.

November 9, 2011

Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.

July 11, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.

November 22, 2017

Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

December 6, 2017

Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.

October 15, 2008

FactFinders.

February 27, 2019

WebAIRS Anesthesia Incident Reporting System.

January 1, 2009

Oxford Professional Practice: Handbook of Patient Safety.

July 27, 2022

How medical jargon can make COVID health disparities even worse.

June 9, 2021

Related Resources

Respectful Maternity Care: Dissemination and Implementation of Perinatal Safety Culture to Improve Equitable Maternal Healthcare Delivery and Outcomes.

January 10, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

November 15, 2023

A Transformational Effort on Patient Safety.

September 13, 2023

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

September 6, 2023

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

September 6, 2023

Amid lack of accountability for bias in maternity care, a California family seeks justice.

August 16, 2023

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

August 16, 2023

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

July 5, 2023

Causes for medical errors in obstetrics and gynaecology.

June 28, 2023

After Roe: Challenges in the Provision of Lifesaving Care.

June 21, 2023

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

June 7, 2023

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

May 31, 2023

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

May 31, 2023

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

May 18, 2023

The time is now: addressing implicit bias in obstetrics and gynecology education.

May 17, 2023

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

May 10, 2023

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

April 26, 2023

Tools for establishing a sustainable safety culture within maternity services: a retrospective case study.

April 26, 2023

Saving Moms.

April 19, 2023

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Mothers face broken addiction treatment system.

April 12, 2023

Care Delivery within Community Mental Health Teams.

April 5, 2023

Perspective

Maternal Safety and Perinatal Mental Health

March 29, 2023

Journal Article

Study

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

March 29, 2023

Addressing Medical Gaslighting to Improve Maternal Health—Together.

March 29, 2023

Interview

In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health

March 28, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

February 22, 2023

See More About The Topic

General Public

Labor and Delivery

Ambulatory Clinic or Office

Policy Makers

Obstetrics