NHS England » Screening Quality Assurance visit report – Liverpool Women’s NHS Foundation Trust

Scope of this report

Service*	Provider	Within the scope of this visit
Sickle cell and thalassaemia screening laboratory services	Full blood count: Liverpool University Hospitals NHS Foundation Trust HPLC: Liverpool University Hospitals NHS Foundation Trust	No
Infectious diseases screening laboratory services	HIV: Liverpool University Hospitals NHS Foundation Trust Hepatitis B: Liverpool University Hospitals NHS Foundation Trust Syphilis: Liverpool University Hospitals NHS Foundation Trust	No
Fetal anomaly screening – combined screening services	Dating/NT scan: Liverpool Women’s NHS Foundation Trust Screening laboratory: Birmingham Women’s and Children’s Hospital NHS Foundation Trust	Yes
Fetal anomaly screening – quadruple screening laboratory services	Dating scan: Liverpool Women’s Hospital NHS Foundation Trust Screening laboratory: Birmingham Women’s and Children’s Hospital NHS Foundation Trust	Yes
Fetal anomaly screening – NIPT screening laboratory services	Birmingham Women’s and Children’s Hospital NHS Foundation Trust	Yes
Fetal anomaly screening – 20-week screening scans	Liverpool Women’s NHS Foundation Trust	Yes
Diabetic eye screening	Liverpool and North Mersey Diabetic Eye screening Programme	Yes
Newborn and infant physical examination	Liverpool Women’s Hospital NHS Foundation Trust	Yes
Newborn blood spot screening laboratory services	Alder Hey Children’s NHS Foundation Trust	No
Newborn hearing screening programme	Liverpool Women’s NHS Foundation Trust	No
Child Health Information Service (CHIS)	South Central and West Commissioning Support Unit	Yes

Screening laboratories are quality assured by the United Kingdom Accreditation Service (UKAS).

Summary

Quality assurance looks at the antenatal and newborn screening pathways starting with identifying the eligible population of pregnant women and babies. It also includes the relevant screening tests for each programme. For women and babies with screen positive/higher chance results it will also include the pathways for referral, diagnosis and/or treatment.

The findings in this report relate to the quality assurance visit on 20 June 2024 to Liverpool Women’s NHS Foundation Trust Screening Service which is commissioned by North West Public Health Commissioning team. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.

We use the term ‘woman’ or ‘mother’ to encompass all gender identities and is intended for anyone who is pregnant. Similarly, where the term ‘parents’ is used, this encompasses anyone who has main responsibility for caring for the baby.

Quality assurance purpose and approach

Quality assurance (QA) aims to achieve and maintain national standards, promote continuous improvement in antenatal and newborn (ANNB) screening and support reducing health inequalities. This is to ensure all eligible people have access to a consistent high quality, effective, equitable and safe service wherever they live.

QA visits are carried out by the NHS England Screening Quality Assurance Service (SQAS).

The evidence for this report comes from the following sources:

monitoring of routine data collected by NHS England
data and reports from external organisations
evidence submitted by the provider(s) and external organisations
discussion with the commissioner in advance of the visit
information collected during pre-visit interview with screening support sonographer on 12 June 2024
information shared with the SQAS as part of the visit process

The screening service

Liverpool Women’s NHS Foundation Trust was established in 1995 when all servies for women and babies in Liverpool came together under one organisation. The trust achieved foundation trust status in 2005.

It is a specialist trust providing maternity, gynaecology and genetics services to the diverse population of Liverpool and the North Mersey conurbation. The hospital is the largest single site maternity hospital in the UK and the specialist provider in Cheshire and Merseyside for high risk maternity care, including fetal medicine services and neonatal care.

The trust is part of the Liverpool Neonatal Partnership with Alder Hey Children’s NHS Foundation Trust. The two organisations work in partnership to deliver a neonatal service across both hospital sites.

Liverpool Women’s Hospital (LWH) is the main site for maternity services offering both inpatient and outpatient services, including tertiary fetal medicine unit and a level 3 neonatal unit. The trust began providing services at the Aintree Centre for Women’s Health in 2000, including antenatal clinic and ultrasound scanning service to pregnant women from north Liverpool, Sefton and Knowsley.

Scan and outpatient antenatal clinics are offered additionally at community clinics in Kirkby, Speke and Bootle.

The newborn hearing screening programme (NHSP) is provided by Liverpool Women’s NHS Foundation trust. NHSP was not included in the scope of the visit.

LWH borders with maternity services at Whiston Hospital and Ormskirk District General Hospital, both part of Mersey and West Lancashire Teaching Hospitals NHS Trust.

South Central and West Commissioning Support Unit (SCW) provide the Child Health Information Service (CHIS) across Cheshire and Merseyside, including Liverpool sub-integrated care board location.

Findings

Antenatal and newborn screening at Liverpool Women’s NHS Foundation Trust is a patient focused service delivered by an experienced screening team clearly committed to the care of pregnant women and babies.

The screening midwives are dedicated and hardworking, supported by a wider multi-disciplinary team across all programmes. There are skilled and dedicated staff across the screening programmes, including the screening support sonographers and sonography workforce.

The maternity leadership team have oversight of the antenatal and newborn screening programmes. The head of midwifery provides strategic leadership of the service to drive quality improvement and provide assurance that the screening programmes can be maintained and safely delivered.

Immediate concerns

The QA visit team identified no immediate concerns

High priority findings

The QA visit team identified 3 high priority findings as summarised below:

elements of the antenatal and newborn screening guidelines are out of line with national screening guidance and policy.
guidelines and policies are not developed within a multi-disciplinary/departmental approach
the trust does not meet the acceptable threshold for for standard FASP-S08a: proportion of women where an unexpected finding is suspected or confirmed in the baby at the 20-week screening scan – timely referral (local).

Examples of practice that can be shared

The QA visit team identified several areas of practice for sharing, including:

development of the newborn and infant physical examination (NIPE) practitioner passport
focus on addressing and reducing health inequalities within the maternity service
investment in ‘interpreter on wheels’ units
neonatal partnership working with Alder Hey Children’s NHS Foundation Trust, including implementation of national newborn IT systems
a named clinical lead for each screening programme to ensure oversight and governance of the local screening programmes

Recommendations

The following recommendations are for the provider to action unless otherwise stated.

No.	Recommendation	Reference	Timescale		Priority		Evidence required

Service provider and population served
No recommendations made in this section
Governance and leadership
01	Make sure there is a documented process for the reporting and management of screening incidents in line with national guidance	Managing safety incidents in NHS screening programmes updated 2024	3 months		Standard		Guideline (that is signed off)
02	Work with the Public Health Commissioning team to develop and complete a health equity audit	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025 Antenatal and newborn screening pathway requirements specifications 2021	12 months		Standard		Completed audit Audit action plan
03	Change guidelines to comply with national policy	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 *[delete as appropriate] 2024 – 2025 Antenatal and newborn screening pathway requirements specifications 2021	12 months		High		Guidelines (that are signed off)
04	Implement a multidisciplinary/departmental approach to the development of guidelines	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 *[delete as appropriate] 2024 – 2025 Antenatal and newborn screening pathway requirements specifications 2021	6 months		High		Guidelines (that are signed off) Documented process (that is signed off)
05	Make sure processes are documented for the failsafe of the screening programmes, including contingency arrangements in the absence of the failsafe officer	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025 Antenatal and newborn screening pathway requirements specifications 2021	6 months		Standard		Documented process (that is signed off)
06	Child health information service to update guideline to describe the process for screening incidents in line with national guidance	Managing safety incidents in NHS screening programmes updated 2024	3 months		Standard		Guideline (that is signed off)
07	Make sure that ANNB screening specific audits are included on the organisations audit schedule with oversight of audit completion and associated action plan monitored at the trust screening steering group	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025 Antenatal and newborn screening pathway requirements specifications 2021	12 months		Standard		Organisation audit schedule Action plan monitored at trust screening steering group
08	Demonstrate that feedback (including complaints) from service users, including those with protected characteristics or from underserved groups is used to develop and/or improve service delivery for antenatal and newborn screening	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 *[delete as appropriate] 2024 – 2025 Antenatal and newborn screening pathway requirements specifications 2021	12 months		Standard		User feedback findings action plan discussed at the screening group and/or programme board
Infrastructure
09	Implement and monitor a process to ensure all healthcare professionals delivering the infectious diseases in pregnancy screening programme complete the IDPS e-learning resource every 12 months	Section 7a screening service schedule 2 no: 18 2024 – 2025 Infectious diseases in pregnancy screening pathway requirements specification 2021	6 months		Standard		Training log / completion of IDPS e-Learning resources (with dates)
10	Make sure the screening support sonographer (SSS) has dedicated time to complete the functions of the role	Section 7a screening service schedule 2 no: 16 2024 – 2025 Fetal anomaly screening pathway requirements specification 2021 Fetal anomaly screening programme handbook 2024	3 months		Standard		Rostered time / job plan
Identification of cohort (antenatal)
11	Make sure all women who miscarry or terminate their pregnancy after antenatal screening receive their results and are followed up as required	Section 7a screening service schedule 2 no: 15, 18 2024 – 2025 Sickle cell and thalassaemia screening pathway requirements specification 2021 Infectious diseases in pregnancy screening pathway requirements specification 2021 Infectious diseases in pregnancy screening programme handbook 2023	3 months		Standard		Guideline (that is signed off) Tracking system
Identification of cohort (newborn)
12	Implement a process for allocating NHS numbers for babies in cases where the maternity IT system fails	Section 7a screening service schedule 2 no: 19, 20, 21 2024 – 2025 Newborn screening pathway requirements specifications 2021 Child Health Information Services provider service specification 2024 – 2025	6 months		Standard		Guideline (that is signed off) Business continuity plan (that is signed off)
13	Implement a process for notifying key stakeholders about babies who die including updating the baby’s status as deceased on the Smart4NIPE and Newborn blood spot failsafe national IT system	Section 7a screening service schedule 2 no: 19, 20, 21 2024 – 2025 Newborn screening pathway requirements specifications 2021	6 months		Standard		Guideline (that is signed off)
Invitation and access
No recommendations made in this section
Sickle cell and thalassaemia screening
14	Implement and monitor a plan to meet the acceptable threshold for standard/key performance indicator SCT-S03/ST3 – the proportion of antenatal SCT samples submitted to the laboratory accompanied by a completed family origin questionnaire	Section 7a screening service schedule 2 no: 18 2024 – 2025 Sickle cell and thalassaemia screening pathway requirements specification 2021 Standards 2018 SCT-S03	12 months		Standard		Submission of data for standard /key performance indicator SCT-S03/ST3 Action plan that is agreed and monitored by the screening group and programme board
15	Document a process for direct referral for counselling and offer of prenatal diagnosis for couples or women known to be at risk of sickle cell or thalassaemia	Section 7a screening service schedule 2 no: 18 2024 – 2025 Sickle cell and thalassaemia screening pathway requirements specifications 2021	3 months		Standard		Documented process (that is signed off)
Infectious diseases in pregnancy screening
16	Make sure each woman who declines the initial offer of IDPS screening (HIV, hepatitis B and/or syphilis) is identified, tracked and re-offered screening by 20 weeks of pregnancy or within 2 weeks if booked after 20 weeks gestation	Section 7a screening service schedule 2 no: 15 2024 – 2025 Infectious diseases in pregnancy screening pathway requirements specification 2021 Infectious diseases in pregnancy screening programme handbook 2023	6 months		Standard		Guideline (that is signed off) Confirmation of tracking system Audit of declines Submission of coverage key performance indicator data (ID1, ID3 and ID4) with commentary
17	Update the IDPS guideline to make sure there is a local policy in place for the care of babies born to women that have declined IDPS screening	Section 7a screening service schedule 2 no: 15 2024 – 2025 Infectious diseases in pregnancy screening pathway requirements specification 2021 Infectious diseases in pregnancy screening programme handbook 2023	6 months		Standard		Guideline (that is signed off)
18	Implement and monitor a plan to meet the acceptable proportion of women with confirmed screen positive results attending an appointment in less than or equal to 5 working days to discuss their results for standard IDPS-S05b (hepatitis B)	Section 7a screening service schedule 2 no: 15 2024 – 2025 Infectious diseases in pregnancy screening pathway requirements specifications 2021 Standards 2023 IDPS-S05	12 months		Standard		Submission of data for standard IDPS-S05 Action plan that is agreed and monitored by the screening group and programme board
19	Implement and monitor a plan to meet the acceptable threshold for standard /key performance indicator IDPS-S06/ID2 – the proportion of women with hepatitis B attending an appointment less than or equal to 6 weeks (42 calendar days) for an assessment by specialist hepatitis B services	Section 7a screening service schedule 2 no: 15 2024 – 2025 Infectious diseases in pregnancy screening pathway requirements specifications 2021 Standards 2023 IDPS-S06	12 months		Standard		Submission of data for standard /key performance indicator IDPS-S06/ID2 Action plan that is agreed and monitored by the screening group and programme board
20	Put in place a process to ensure that the screening team are informed when babies are born to IDPS screen positive mothers	Section 7a screening service schedule 2 no: 15, 16, 17 2024 – 2025 Fetal anomaly screening pathway requirements specification 2021 Clinical review checklist for antenatal and newborn screening 2023	6 months		Standard		Documented process (that is signed off)
Fetal anomaly screening
21	Implement and monitor a process to make sure all women who need more information at the point of FASP screening have access to a healthcare professional for further discussion	Section 7a screening service schedule 2 no: 16 2024 – 2025 Fetal anomaly screening pathway requirements specification 2021	6 months		Standard		Guideline (that is signed off)
22	Implement and monitor a plan to meet the acceptable threshold for standard FASP-S08a – proportion of women where an unexpected finding is suspected or confirmed in the baby at the 20-week screening scan – timely referral (local)	Section 7a screening service schedule 2 no: 17 2024 – 2025 20-week screening scan pathway requirements specification 2021 Standards 2022 FASP-S08a	12 months		High		Submission of data for standard FASP-S08a Action plan that is agreed and monitored by the screening group and programme board
23	Put in place a process to ensure that the screening team are informed when babies are born unexpectedly with one of the FASP conditions	Section 7a screening service schedule 2 no: 15, 16, 17 2024 – 2025 Fetal anomaly screening pathway requirements specification 2021 Clinical review checklist for antenatal and newborn screening 2023	6 months		Standard		Documented process (that is signed off)
Diabetic eye screening in pregnancy
24	Make sure there is a written guideline for diabetic eye screening in pregnant women that is agreed with the local diabetic eye screening programme (DESP)	Section 7a screening service schedule 2 no: 22 2024 – 2025 Diabetic eye screening pathway requirements specification 2021	3 months		Standard		Guideline (that is signed off) agreed with local DESP
25	Document the failsafe process to identify and track eligible women – pregnant women with existing type 1 and type 2 diabetes	Section 7a screening service schedule 2 no: 22 2024 – 2025 Diabetic eye screening pathway requirements specification 2021	6 months		Standard		Guideline (that is signed off)
Newborn and infant physical examination
26	Implement and monitor a plan to meet the acceptable threshold for standard NIPE-S03 – the proportion of babies with a screen positive newborn hip result who attend for ultrasound scan of the hips within the designated timescale	Section 7a screening service schedule 2 no: 21 2024 – 2025 Newborn and infant physical examination screening pathway requirements specification 2021 Standards 2024 NIPE-S03		12 months		Standard	Submission of data for standard NIPE-S03 Action plan that is agreed and monitored by the screening group and programme board
Newborn blood spot screening
27	Implement and monitor a plan to meet the acceptable threshold for standard /key performance indicator NBS-S06/NB2 – the proportion of first blood spot samples that require repeating due to an avoidable failure in the sampling process	Section 7a screening service schedule 2 no: 19 2024 – 2025 Newborn blood spot screening pathway requirements specification 2021 Standards 2021 NBS-S06	12 months		Standard		Submission of data for standard /key performance indicator NBS-S06/NB2 NB2 check list and action plan that is agreed and monitored by the screening group and programme board
28	Implement a process to inform the GP and health visitor when a parent or carer declines NBS screening and to send national template letter to parent or carer to confirm their decision and the option to change their mind	Section 7a screening service schedule 2 no: 19 2024 – 2025 Newborn blood spot screening pathway requirements specification 2021	6 months		Standard		Documented process (that is signed off)
29	Child health information service to implement national NBS status sub- codes to include not contactable, reasonable effort made and screened outside of UK (with evidence/no evidence of result) for movers in	Section 7a screening service schedule 2 no: 19 2024 – 2025	3 months		Standard		Submission of data with mitigations for standard NBS-S01b (KPI NB4): coverage of movers in
30	Implement and monitor a plan to meet the acceptable threshold for standard NBS-S03 – the proportion of blood spot cards received by the laboratory with the baby’s NHS number on a barcoded label	Section 7a screening service schedule 2 no: 19 2024 – 2025 Newborn blood spot screening pathway requirements specification 2021 Standards 2021 NBS-S03	12 Months		Standard		Submission of data for standard NBS-S03 Action plan that is agreed and monitored by the screening group and programme board

Next steps

The screening service is responsible for developing an action plan in collaboration with the commissioners to complete the recommendations contained within this report.

SQAS will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point SQAS will send a letter to the provider and commissioners summarising progress made and will outline any further action(s) needed.

Appendix G: References

Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
NHS England Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) Serious-incident-framework
NHS population screening standards NHS population screening standards
NHS population screening: pathway requirements specifications and learning from screening incidents Population screening: pathway requirements specifications
PHE Screening inequalities strategy PHE Screening inequalities strategy
Public Health Profiles Public health profiles https://fingertips.phe.org.uk/
Section 7a screening service schedule 2. DESP Schedule 2 2022-23 – NHS Public Health Commissioning & Operations – FutureNHS Collaboration Platform
Section 7a screening service schedules 2. ANNB – NHS Public Health Commissioning & Operations – FutureNHS Collaboration Platform

There is more detailed information on individual screening programmes, including handbooks and operational guidance, that can be access via Population screening programmes: detailed information

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