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London, UK: Royal College of Obstetricians and Gynaecologists; 2016.
This report highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm.
Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.
Sharing information about large-scale investigations into failures can provide insights on factors that contribute to adverse clinical incidents. This report discusses an analysis of care delivered in the maternity unit of a National Health Service Trust between 2004 and 2013 which uncovered problems that were perpetuated due to failure to look into the initial event.