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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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Briefing paper: Remote hospital working

Briefing paper

A thematic review was conducted to explore the impact that remote hospital working can have on the provision of maternity and neonatal services.
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Safety spotlight: Calling for help in obstetric cardiac arrests

Safety spotlight

This safety spotlight focuses on delays in calling the emergency team during obstetric cardiac arrests.
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Safety spotlight: Nitrous oxide

Safety spotlight

This safety spotlight shares what we found regarding nitrous oxide decommissioning and offers prompts to help providers keep staff informed and equipment checks consistent.
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