There is a significant risk to hundreds of babies and children because of inconsistent practice and a lack of clear guidance on treatment, an investigation by the Care Quality Commission has found.
The watchdog uncovered concerns about the way the NHS identifies and manages clinical risk in unborn and newborn babies, in the first report of its kind, published today.
“We found a great deal of variation in the way that services manage clinical risks in babies”
It also raises fears that key information might not be shared between clinical teams and says there needs to be more consistent support for families with children requiring long term ventilation at home.
Among its recommendations for improvement, the CQC said every unborn fetus should be assigned a unique identification number to ensure important information from a mother’s clinical notes is properly transferred to the baby’s records after birth.
The report authors have also secured agreement from the National Institute for Health and Care Excellence to develop new guidelines on identifying and managing fetal anomalies, both before and after birth, as well as guidelines on assessing blood pressure in babies and children.
The investigation was prompted by the case of baby Elizabeth Dixon who was born at Frimley Park Hospital in 2000 and was left with permanent brain damage, after hospital staff failed to monitor or treat her high blood pressure.
She suffocated to death a year later when a newly qualified nurse failed to keep her breathing tube clear. The cause of her brain damage was only revealed in 2013.
The CQC and NHS England were due to carry out an independent investigation into Elizabeth’s care in 2014, but NHS England pulled out at the last minute. As a result, the CQC agreed to examine the wider themes raised by Elizabeth’s case to identify any gaps in current practice.
It examined practise at 19 acute hospitals and took evidence from commissioners, and from families whose children require ventilation support at home.
It considered three areas of care including the detection of health problems during pregnancy through screening; the diagnosis and management of newborn babies with a focus on high blood pressure; and the management of infants requiring long term ventilation in the community. It also considered blood pressure among children more generally, in response to concerns raised by Elizabeth’s parents.
Regulator to review care for newborns following baby’s death
CQC deputy chief inspector of hospitals Edward Baker said: “There is no doubt about the dedication and skills of staff that provide this very specialist care. However, we found a great deal of variation in the way that services manage clinical risks in babies before and immediately after birth, and in the management of infants that need support once discharged home.
“For all anomalies detected during pregnancy communication between specialist teams is essential,” he said. “However, when major problems are identified, multidisciplinary meetings need to take place including obstetrics, fetal medicine and neonatal specialists. In some hospitals, this is routine, but in others it isn’t always happening.
“Parents need to be confident that newborn babies who need the most complex care will receive the same high standards wherever they live. Similarly, families of children who need long-term ventilation at home need to be confident that they can rely on professional, well-trained staff to care for their child after they leave hospital,” said Mr Baker.
He added: “We have identified a requirement for clinical guidance to ensure consistent high quality care across the country and we are grateful for the support of our partner organisations in taking this forward.”
It is the first time the CQC has done a report on specific areas of clinical care, and Professor Baker said he believed the model could be used in future to identify other areas needing improvement.
“It is vital that these recommendations are considered as a matter of urgency”
The Royal College of Nursing, Royal College of Paediatrics and Child Health, the Royal College of Midwives and the British Association of Perinatal Medicine have agreed to work to ensure practice in the areas of care reviewed is more consistent.
After Nursing Times’ sister title Health Service Journal highlighted the failure of national organisations to investigate Elizabeth’s death last year, health secretary Jeremy Hunt intervened and ordered an independent inquiry. This will be led by former Mid Staffs Inquiry adviser Peter Hutton.
Health minister Ben Gummer said today: “It is vital that these recommendations are considered as a matter of urgency. There are unacceptable variations in neonatal care and ensuring the very best and safest care for sick babies is essential.
“This government is absolutely committed to improving maternity care – which is why we have set out our intention to halve the number of neonatal deaths by 2030 and have invested millions in training for staff and new safety equipment, as well as making sure hospitals review and learn from every tragic case,” he said.
Jane Munro, quality and audit development advisor at the Royal College of Midwives, said: “This is a useful report highlighting the national variation in practice and the importance of good communication processes for sharing information between all the stakeholders when any problems are detected through screening in pregnancy.”
“We fully support the recommendation that NICE should develop national guidance for health practitioners, providers and commissioners about the discharge pathway from hospital to home and about caring for infants who need long-term ventilation in the home,” she added.