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RCOG response to Maternity and Newborn Safety Investigations national learning report

9 May 2024

The report identifies key themes from investigations where safety recommendations were made to midwife led units in NHS hospital trusts. 

The Royal College of Obstetricians and Gynaecologists (RCOG) welcomes this report, providing valuable further learnings and prompts focused on mitigating maternity safety risks and driving improvements in care. Themes include insufficient staffing levels to respond to work demands and a need for maternity teams to improve preparedness for predictable safety critical scenarios.

The MNSI report highlights variation in the advice and information given to pregnant women during telephone triage, and references the recent RCOG Maternity Triage Good Practice Paper. The College urges Trusts to implement the Good Practice Paper recommendations, including around standardising telephone triage assessments.

Intermittent auscultation was not carried out in line with national guidance in almost half (49%) of the maternity investigations analysed. The RCOG encourages midwifery unit teams to watch the intrapartum fetal heart monitoring webinar available online, developed by the RCOG and Royal College of Midwives to support improvement in professional standards in this area.

Dr Ranee Thakar, President of the Royal College of Obstetricians and Gynaecologists, said: “The RCOG supports maternity services within the system through its role as an educator; developing the curriculum, improving standards of care through clinical guidance, supporting career development through exams, facilitating professional development courses and events, and support services for its members. We are committed to maternity safety improvement, working with partners including MNSI, NHS England, the Royal College of Midwives and policy makers.

“Across maternity services, multidisciplinary teams are skilled at working together to deliver high quality care, and taking urgent action when complications arise. However, the inescapable reality is maternity services are under incredible strain and this report reinforces the need for sufficient, dedicated Government funding for maternity services. This is vital to ensuring that our multi-disciplinary maternity teams are able to respond to growing working demands and provide consistent and compassionate care.”

Further information:

  • Read about the RCOG’s maternity safety programme here.
  • Read the RCOG’s good practice paper on maternity triage here.
  • Watch the RCOG’s webinar on Intrapartum fetal heart monitoring here.
  • Read the full paper from MNSI here.
  • Careers and workforce
  • Policy and governance
  • Pregnancy and birth