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The report is based on an examination of individual HSIB maternity investigations which had flagged up the theme of ‘incomplete risk assessment.’ The investigations had shown repeated examples of insufficient robust and continuous risk assessments and a thematic review of reports between April 2019 and January 2022 found 208 reports that had made findings and recommendations to NHS trusts about risk assessments.

Our review is clear on the risks that are associated with insufficient risks assessments – pregnant women/people could be on the incorrect care pathway or being in the wrong place of care for their pregnancy or labour. This in turn could lead to delayed decision making or timely escalation of care to meet the needs of the pregnant woman/person and their baby. On some occasions this could result in significant harm to or death of the baby.

Pregnant women/people undergo several risk assessments throughout the maternity pathway and the number of assessments performed will depend on a variety of factors, including those risks identified for an individual at the initial booking appointment. The report states that maternal risk assessments should be dynamic, adaptive and that there needs to be acknowledgement that a pregnant women/person’s ‘risk profile’ may change as they move along their pathway.

Standardising care

The review found that, at time of writing the report, there is no single national standard for risk assessment in maternity care.

There are multiple guidelines on differing pregnancy conditions that involve guidance on risk assessment that are available from national organisations, including the Royal College of Obstetricians and Gynaecologists and the National Institute for Health and Care Excellence. One of the conclusions in this report is that ‘traditionally, risk assessments have been thought of as occurring at certain stages of pregnancy. However, it is very apparent that continual risk assessments are needed during pregnancy, labour and birth.’

Our findings align with those in recent high-profile publications such as the Ockenden Review and the Kirkup report into East Kent Maternity Care. The main learning point emerging from the review is the need to facilitate and support individualised risk assessments for pregnant women/people.

As a result, seven ‘risk assessment’ themes have been identified as appearing in the HSIB reports and set out in the review to aid improvement and ensure safer maternity care.

Adding to this, the report also has seven prompts to help NHS Trusts consider how certain risks might be mitigated.

Seven themes for learning

  1. The language used to discuss and document risk assessments should encourage a dynamic and holistic assessment of the individual pregnant woman/person’s risk (‘dynamic’ means the risk is continually assessed to allow for unknown factors and to handle uncertainty, while ‘holistic’ refers to looking at other factors that might be relevant) that promotes the need for maternity care to be provided by multi-professional teams.
  2. Telephone triage services should support 24-hour access to a systematic structured risk assessment of pregnant women/people’s needs.
  3. Telephone triage services should be operated by appropriately trained and competent clinicians who are skilled in the specific needs required for effective telephone triage.
  4. Face-to-face triage in maternity units should use a structured approach to prioritise pregnant women/people to be seen in order of clinical need.
  5. Clinicians should be enabled to proactively monitor and recommend the place of labour care and birth for pregnant women/people based on the individual’s specific care needs during the course of their pregnancy and labour.
  6. Each pregnant woman/person should be helped to understand their individualised risk associated with a vaginal or caesarean birth after a previous caesarean birth, based on their specific risk factors and care needs.
  7. Pregnant women/people whose labour has been induced need clinical oversight and an individualised plan of care for maternal and fetal monitoring.

Despite a wealth of national guidance, our evidence suggests that risk assessments in the maternity pathway remain a significant challenge and that they are not always robust as they should be. Our maternity investigations alerted us to this risk as we saw it emerging in all regions and we felt that conducting a thematic review would provide learning opportunities for NHS trusts across England.

As we have concluded in our report: risk assessments should not be tick box exercises. Maternity care should move from a ‘binary low/high risk’ model and should be focused on responding and adapting to the individual needs and risks to the pregnant woman/person and baby. Our report is shining the light on the importance of understanding what those risks might mean for the individual’s whole pathway and not just certain times.

Our review is aimed at highlighting the need for a personalised dynamic risk assessment approach. The seven themes we have set out in our review can be used by those working in the maternity system to mitigate risks and ensure the safest care for mothers and babies.

— Sandy Lewis, Associate Director of Maternity Investigations

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