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Portsmouth Hospitals NHS Trust

Below is one of the case studies written by contributors to the Each Baby Counts project.

Portsmouth Hospitals NHS Trust

Sharon Hackett, EBC Lead Reporter (Senior Midwifery Manager Clinical Governance, Lead for Midwifery Practice Education)

Portsmouth Hospitals NHS Trust Maternity Services have agreed criteria for identifying potential Serious Incident Requiring Investigations (SIRI).  One of the criterions is a term baby who is admitted to the neonatal intensive care unit for therapeutic cooling. The service follows the trust process by writing a detailed initial management report, which is presented to a multiprofessional team. The team would assess whether the service has caused harm and then grade the event. In the case of no harm, the process would stop.  The parents would be informed and a postnatal follow up appointment to discuss the case would be arranged. 

At the Each Baby Counts event in June 2016 it became apparent that significant changes in process should be considered. Not only was it identified that there was a need to learn from good care as well as sub-optimal care but also the parents voice should be an integral part of the investigation process. 

As a result this service has implemented family involvement in the investigation process by sending a ‘duty of candour’ letter which invites them to meet with the service to ensure their questions, thoughts and feelings form part of the key lines of enquiry.  This conversation is recorded with consent but if they feel unable to meet face to face, then the option to email their questions is given and the service respects whatever the family decide. This inclusive approach is family centred and enables the service to answer questions that may not have been identified as part of the root cause analysis investigation. 

In addition, since the Each Baby Counts event, a full root cause analysis is now undertaken for any baby who requires therapeutic cooling. Lessons learned form part of the multi-disciplinary Perinatal Morbidity and Mortality meeting for which midwives have now been given protected time to attend.

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