Letters sent to trusts
Letters
Read the letters previously sent to trusts
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Maternal Care Bundle safety spotlights
Safety spotlight
We welcome the publication of the Maternal Care Bundle by NHS England and are delighted to have been a key contributor in its development. A series of safety spotlights follow.
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Safety Spotlight: Investigations into equipment and technology used for continuous fetal heart rate monitoring
Safety spotlight
MNSI has completed Investigations into equipment and technology used for continuous fetal heart rate monitoring.
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Safety spotlight: Late diagnosis of breech presentation
Safety spotlight
MNSI has completed a number of investigations where there has been a late diagnosis, in established labour, of a baby being in breech presentation during an induction of labour.
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Safety Spotlight: Therapeutic cooling practices
Safety spotlight
Our investigations into therapeutic cooling practices have identified areas of learning in relation to passive cooling.
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Safety Spotlight: Exchange blood transfusion
Safety spotlight
A baby received an exchange blood transfusion. This is a specialist and complex procedure with associated risks (and is now infrequently performed in most neonatal units).
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Safety Spotlight: Delayed escalation in abnormal CTGs
Safety spotlight
MNSI has completed a number of investigations in which time limits, as described in national guidance, have delayed categorisation of CTG recordings, resulting in delays in escalation.
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Safety Spotlight: Deaths from Anaphylaxis
Safety spotlight
MNSI is aware of maternal deaths from anaphylaxis.
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Safety spotlight: Reviewing and actioning laboratory test results
Safety spotlight
MNSI has undertaken investigations where laboratory test results have not been reviewed and actioned.
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Safety spotlight: Mothers with a learning disability
Safety spotlight
Maternity care should be responsive to every woman’s needs.
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