Through its core work to review patients safety events 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 an issue of women not receiving an ultrasound scan prior to an elective caesarean section for breech presentation.
If the baby is known to be in the breech (bottom first) presentation towards the end of pregnancy, the woman should be given the option of an elective caesarean section. While not captured in national guidance, routine practice in many maternity units is for an ultrasound to be performed on the day of, or prior to, elective caesarean section as a final check to see if the baby has moved into a head down position meaning a caesarean may not be required.
The team identified an incident where an ultrasound was not performed, and the baby was found to be in the cephalic (head down) presentation at birth. This meant that the woman had an unnecessary caesarean section.
The team worked with the Royal College of Obstetricians and Gynaecologists to agree what good practice in respect of this should be. The insight was shared with NICE who updated the Caesarean birth (nice.org.uk) Guideline to include a specific recommendation on carrying out an ultrasound scan prior to elective caesarean section for breech presentation.
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.