Through its targeted surveillance of emerging COVID-19 issues recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a risk of babies becoming unwell when virtual home midwife visits replaced face-to-face visits.
New mothers and babies normally receive a face-to-face visit by a midwife the day after discharge. This enables the midwife to check that both are well and helps identify signs of illness. During the height of the COVID-19 pandemic modifications to maternity services were made, including the introduction of virtual appointments (either by phone or video).
National guidance at that time stipulated a face-to-face visit on day 1, day 5 and day 10 following birth. Many mothers and babies are still in hospital on day 1 and so would not receive a face-to-face visit at home until day 5.
The National Patient Safety Team identified several incidents where the first home visit by the midwife was virtual with a face-to face visit on day five. When weighed at day five, these babies had lost more weight than expected and were significantly jaundiced and dehydrated resulting in transfer to a neonatal unit for treatment.
The team worked with the Royal College of Obstetricians and Gynaecologists and the Royal College for Midwives (RCM) to amend guidance to clearly state the initial visit, following either transfer home from a hospital birth or the day after a homebirth, should be face-to-face. The RCM also agreed to publish advice for healthcare professionals on how to perform effective virtual consultations.
Day 1 face-to-face consultation was also highlighted by NHS England and NHS Improvement via a social media campaign and via the Regional Chief Midwives and service user networks.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare.
A core part of the work of the National Patient Safety Team is to review these records to identify new or under recognised patient safety risks, which are often not obvious at a local level. In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.