NHS England » Screening Quality Assurance visit report – St Georges University Hospital 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: HPLC: South West London Pathology	No
Infectious diseases screening laboratory services	HIV: Hepatitis B: Syphilis: South West London Pathology Some of these samples may be sent to a confirmatory laboratory	No
Fetal anomaly screening – combined screening services	Dating/NT scan: St George’s University Hospital NHS Foundation Trust Screening laboratory: Barking, Havering and Redbridge University Hospitals NHS Trust	Yes No
Fetal anomaly screening – quadruple screening laboratory services	Dating scan: St George’s University Hospital NHS Foundation Trust Screening laboratory: Barking, Havering and Redbridge University Hospitals NHS Trust	Yes No
Fetal anomaly screening – NIPT screening laboratory services		No
Fetal anomaly screening – 20-week screening scans	St George’s University Hospital NHS Foundation Trust	Yes
Diabetic eye screening	South West London Diabetic Eye Screening Programme	No
Newborn and infant physical examination	St George’s University Hospital NHS Foundation Trust	Yes
Newborn blood spot screening laboratory services	South West Thames	Yes
Newborn hearing screening programme	South West London NHSP	Yes
Child Health Information Service (CHIS)	Your Healthcare	Yes

*add additional lines if the screening provider has more than one laboratory for a specific condition, or works with more than one CHIS, or is part of a hub

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 14 March 2023 to St Georges University Hospital NHS Foundation Trust Screening Service which is commissioned by London 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-review visits to St Georges University Hospital NHS Foundation Trust on 22 February 2023, 10 March 2023 and 14 March 2023
information shared with the London SQAS as part of the visit process.

The screening service

St George’s University Hospitals NHS Foundation Trust serves a population of approximately 1.3 million across the London borough with 4000-4500 births per year. The hospital is one of the country’s principal teaching hospitals and is host to St George’s Medical School and Faculty of Social Care Sciences. The hospital is also one of 4 designated trauma centres in London.

Findings

This is the second quality assurance visit to the Trust, having completed the actions from their previous visit in 2014. The service is delivered by a team of dedicated staff who are committed to quality improvement. There is evidence of good working relationships between staff across the screening programmes.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

The QA visit team identified 6 high priority findings as summarised below:

There is no process to assess the competency of midwives trained prior to 2016 who have not completed a university-accredited examination of the newborn programme of study
There is no formalised process for notifying the screening team of women who book late or present unbooked in labour
There is no formalised process of notifying screening staff of babies who have died
The family origin questionnaire is not up to date
There is no process for notifying women with screen negative results if they have had a pregnancy loss
There is no process for notifying the screening team of babies born to hepatitis B positive women

Examples of practice that can be shared

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

There is a good relationship between early pregnancy unit and maternity with processes in place to support women and meet the screening standards
There are clear communication processes between the screening team and diabetic team regarding DESP screening
The screening team work cohesively and support each other well
The Trust have used videoconferencing for Trust Screening Steering Group meetings since the COVID-19 pandemic which has reduced travel time constraints for some attendees
Each parent is given a quick response (QR) code after their baby’s hearing screen for patient feedback.

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 that Datix forms that are relevant to screening, are notified directly to the screening team	Managing safety incidents in NHS screening programmes 2017	12 months	Standard	Confirmation that maternity can notify the screening team directly from Datix New or revised guidelines/SOPs submitted to the programme board
02	Make sure ANNB screening programme guidelines and standard operating procedures are updated in line with current national screening standards and guidance	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 2022 – 2023; Antenatal and newborn screening pathway requirements specifications 2021	12 months	Standard	Ratified Guidelines
03	Make sure all processes within the ANNB screening programmes are documented	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2022 – 2023; Antenatal and newborn screening pathway requirements specifications 2021	12 months	Standard	Documented processes (that are signed off)
04	Implement a process to make sure the local audit schedule includes antenatal and newborn screening pathway areas that have been identified	Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2022 – 2023; Antenatal and newborn screening pathway requirements specifications 2021	6 months	Standard	1. audit schedule that includes list of audits for ANNB plan 2. minutes from the screening group and/or programme board that includes completed audits and any action plan and shared learning
05	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 2022 – 2023; Antenatal and newborn screening pathway requirements specifications 2021	12 months	Standard	Confirmation of user feedback findings action plan discussed at the screening group and/or programme board
Infrastructure
06	Implement and monitor a process to support continuing professional development for practitioners who perform the newborn examination	Section 7a screening service schedule 2 no: 21 2022 – 2023; Newborn and infant physical examination screening pathway requirements specification 2021; Newborn and infant physical examination programme handbook 2021	6 months	Standard	Training log / completion of NIPE e-Learning resource each year (with dates)
07	Put in place a process to monitor competency of midwives trained prior to 2016 to undertake the NIPE examination	Section 7a screening service schedule 2 no: 21 2022 – 2023; Newborn and infant physical examination screening pathway requirements specification 2021; Newborn and infant physical examination programme handbook 2020	6 months	High	Risk assessment Training competency logs (with dates) Training CPD plans
08	Review and update the job descriptions for the Newborn Hearing Screening Programme team and Screening Support Sonographer	Section 7a screening service schedule 2 no: 16 20 2022 – 2023; Newborn hearing screening pathway requirements specification 2021; Fetal anomaly screening pathway requirements specification 2021; Fetal anomaly screening programme handbook 2022	6 months	Standard	Updated job descriptions
Identification of cohort (antenatal)
09	Implement and monitor a process to make sure that the screening team are notified of all women who present unbooked in labour or with no reliable laboratory evidence of screening results	Section 7a screening service schedule 2 no: 15, 16, 17, 18 2022 – 2023; Antenatal screening pathway requirements specifications 2021	3 months	High	Audit on unbooked women Insert addendum into antenatal guidelines for notifying screening team of unbooked women in labour
10	Implement an electronic process to current antenatal failsafe processes to support the screening team’s oversight of screening results	Section 7a screening service schedule 2 no: 15, 16, 17, 18 2022 – 2023; Antenatal screening pathway requirements specifications 2021	6 months	Standard	Confirmation or Feedback at provider screening meeting that electronic failsafe is in place
Identification of cohort (newborn)
11	Put in place a consistent communication and escalation pathway between NICU and the screening team with oversight and monitoring of all newborn screening related risks	Section 7a screening service schedule 2 no: 19, 20, 21 2022 – 2023; Newborn screening pathway requirements specifications 2021	6 months	Standard	Confirmation at provider screening meeting that an established process for escalation is in place between NICU and screening team
12	Put in place a process for notifying key stakeholders about babies who die including updating the baby’s status as deceased on the NBSFS, SMaRT4Hearing and SMaRT4NIPE systems	Section 7a screening service schedule 2 no: 19, 20, 21 2022 – 2023; Newborn screening pathway requirements specifications 2021	3 months	High	Insert addendum into newborn guidelines on notification processes for babies who die Audit (if available or evidence of monitoring this process)
Invitation and access
	No recommendations made in this section
Sickle cell and thalassaemia screening
13	Change the family origin questionnaire to comply with the current national version	Sickle cell and thalassaemia screening handbook for antenatal laboratories 2022	3 months	High	Revised family origin questionnaire (paper or electronic)
14	Send an alert card to notify the relevant newborn screening laboratory of the woman’s or couple’s ‘at risk’ screening result and their decision to decline PND	Section 7a screening service schedule 2 no: 18, 19 2022 – 2023; Pathway requirements specifications for sickle cell and thalassaemia and newborn blood spot screening 2021	12 months	Standard	Updated sickle cell and thalassemia guideline (that is signed off) Feedback at provider screening meeting
15	Make sure all women who miscarry or terminate their pregnancy after screening receive results and are followed up as required	Section 7a screening service schedule 2 no: 18 2022 – 2023; Section 7a screening service schedule 2 no: 15 2022 – 2023; Infectious diseases in pregnancy screening pathway requirements specification 2021; Infectious diseases in pregnancy screening programme handbook 2016; Sickle cell and thalassaemia screening pathway requirements specification 2021	6 months	High	Updated antenatal guidelines (that are signed off) Tracking system Letter templates
Infectious diseases in pregnancy screening
	See recommendation 9
	See recommendation 10
	See recommendation 15
16	Implement and monitor a process for notifying the screening team of all babies who are born to mothers who are hepatitis B positive	Section 7a screening service schedule 2 no: 15 2022 – 2023; Infectious diseases in pregnancy screening pathway requirements specification 2021; Infectious diseases in pregnancy screening programme handbook 2016; Immunisation against infectious disease: the green book 2021	6 months	High	Updated Infectious Diseases in Pregnancy screening guideline (that is signed off) Tracking process/audit/example of confirmed notification
Fetal anomaly screening
	See recommendation 2
	See recommendation 4
	See recommendation 8
Diabetic eye screening in pregnancy
	No recommendations made in this sections
Newborn hearing screening
	See recommendation 3
	See recommendation 12
Newborn and infant physical examination
	See recommendation 6
	See recommendation 7
	See recommendation 12
17	Make sure there is a process in place to follow up babies who are not brought for screening appointments	Section 7a screening service schedule 2 no: 19, 20, 21 2022 – 2023; Newborn screening pathway requirements specifications 2021	6 months	Standard	Updated NIPE guideline (that is signed off) Tracking process Audit (if available)
18	Notify GP of babies with unilateral undescended testes	Newborn and infant physical examination (NIPE) screening programme handbook	6 months	Standard	Updated NIPE guideline Audit (if available)
Newborn blood spot screening
	See recommendation 12
19	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 2022 – 2023; 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 provider screening meeting
20	Implement and monitor a plan to meet the acceptable threshold for standard NBS-S04 – the proportion of first blood spot samples taken on day 5	Section 7a screening service schedule 2 no: 19 2022 – 2023; Newborn blood spot screening pathway requirements specification 2021; Standards 2021 NBS-S04	12 months	Standard	Submission of data for standard NBS-S04 Action plan that is agreed and monitored by the provider screening meeting
21	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 2022 – 2023; 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 provider screening meeting

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: 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
Section 7a screening service schedule 2. DESP Schedule 2 2022-23 – NHS Public Health Commissioning and Operations – FutureNHS Collaboration Platform
Section 7a screening service schedules 2. ANNB – NHS Public Health Commissioning and 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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