In this report we have focused the thematic analysis on clinical escalation in maternity care.
Successful clinical escalation is a complex process that requires a combination of clinical, behavioural and logistical steps in order to correctly identify and deliver urgent care.
Communication of information to the right people
Civility, psychological safety and a supportive culture
Empowerment to challenge incorrect 'de-escalation'
Availability of the right people at the right time
Correct identification of the problem
In the analysis of Each Baby Counts babies born in 2017, at least one reviewer felt that ‘failure to escalate/act upon risk/transfer appropriately’ occurred in 36% (358/986) of reports.
This was considered to be as a result of either a lack of awareness of deterioration and the need to escalate, or a breakdown in the process of attempted escalation.
Underlying themes were human factors and behaviour, workload and workforce challenges, and errors in communication methods.
Locally, care reviews and investigations should attempt to understand the underpinning conditions for these behaviours and actions, with emphasis on the need for systemic culture changes.
Nationally, infrastructure and staffing must be adequately resourced to make maternity care safer, and the wider workforce challenges of burnout and attrition must be addressed to support and retain current staff.