#endstillbirths: Reasons to be (more) cheerful

This is the oddest position I’ve been in for a while.

I’m used to having to rewrite from scratch as events over take what I’m writing about but never in this way before.  This is in a good way and I’m not used to that.

I had written a beautifully detailed tour of the National Maternity Review picking out the themes of data, willingness to learn from mistakes, a terror of a litigation culture that didn’t exist, working together and training together.

I wrote of all the important findings and how they reinforced the need to take a co-ordinated approach to deal with the underlying factors of culture change.

It was over 2000 words long.  It had choice quotes, interesting diversions…and then…

This week happened.

In a matter of days the Government issued its Spotlight on Maternity guidance along with its Sign up to Safety campaign to get hospitals to commit to the ambition to to halve the rates ofstillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2030

It dealt with data and training and investigating where things go wrong and learning from it.  The hospitals already doing amazing things in terms of multi-disciplinary training and stillbirth investigation are already part of it and it builds on that work along with the good work of #MatExp and #WhoseShoes.

Then something pops up on education and training.

Commission puts human factors centre in 12 recs to improve safety https://t.co/wL2UcoKkWB @ShaunLintern @MartinBromiley

— Prof Jane Reid (@safenursingcare) March 8, 2016

That handles the training point but what is there to deal with the underlying culture issues around reporting and fear?

As if by magic, the next day the Patient Safety Report gets issued along with a paper on better data capture, national sharing of data on incidents to inform learning, including rather than shunning patient involvement and a global perspective.

Well, data is all well and good but what about investigation?

New patient safety body to have a "safe space" for no-blame investigations: https://t.co/BnApBspdyN pic.twitter.com/XhpBNcgvF1

— Shaun Lintern (@ShaunLintern) March 7, 2016

Then the announcement about the Healthcare Safety Investigation Branch and independent review by medical examiners, (both recommendations from the Investigating clinical incidents in the NHS report).

It’s getting silly now.  With every paragraph I type more news flicks into my timeline.  I’m running out of paper to print it all, I’m in danger of getting RSI from mashing the retweet and like icons…

This new innovative project should drive improvements in the care of #twins #triplets in a number of trusts https://t.co/bTufCoFtP3

— Keith Reed (@Tamba_KeithReed) March 9, 2016

Help for improving the chances of twins and multiples!  A subject very close to my heart.

There’s more…

We're aiming to provide bereavement care training to every first and third year student midwife in Scotland https://t.co/yZXKayqfp9

— Sands (@SandsUK) March 10, 2016

Well…what about mental health care for the bereaved?

This is where it gets quieter.  There is a healthy focus on perinatal mental health in the reviews and reports and some great work going on in some Trusts.

Teaching about perinatal mental illness to maternity unit staff as part of their mandatory training today. Love the commitment our trust has

— Mags (@MancMidwife) March 9, 2016

But the reports and reviews are seemingly silent on the need for bereavement care and mental health care once bereaved families leave the hospital.

“…60-70% of grieving mothers in HICs reported grief-related depressive symptoms they regarded as clinically significant 1 year after their baby’s death. These symptoms endured for at least 4 years after the loss in about half of the cases”

I bought this to the attention of two of the members of the All Party Parliamentary Group on Baby Loss (Will Quince and Antoinette Sandbach).

Today @BBCBreakfast highlighted the importance of good #NHSMaternity bereavement care. I will look at this with @willquince + @ASandbachMP

— Ben Gummer (@gummerben) March 8, 2016

But not all good news has to come from the UK.

Perinatal #bereavement and #palliativecare in #Ireland https://t.co/KZ4FHy8oRB @HSElive @PregnancyLossIE @NPEC_UCC @AIIHPC

— Grace O'Sullivan (@graceos101) March 9, 2016

A treasure trove of a blog informed me of the good things happening in Ireland:

As part of the growing recognition of the role maternity services play in bereavement care, Ireland’s Health Service Executive will soon publish an important set of national standards, Bereavement Care Following Pregnancy Loss and Perinatal Death. The aim of the standards is to strengthen and guide the development of a palliative care approach for women, babies and families experiencing loss and grief in Ireland’s maternity services.

After writing so many furious posts on the lack of action and the barriers to improvement this is a great post to be able to write.  So much hope for a more compassionate and safer future it makes me feel less grumpy about the beautifully crafted post in draft.  Being clever, clever is one thing but to be able to share such a collection of great news is far, far better.