Health Services Safety Investigations Body

“times The Trust has in place approved policies for protecting meal times. This includes restricting visiting, visual aids to identify people who require extra support and minimising clinical interactions during meal times. Patients are regularly reviewed using the Malnutrition Universal Screening Tool (MUST) score for nutrition and hydration. We monitor nutrition and hydration through nursing quality metrics and the ward accreditation scheme. Trained volunteers also support patients with their”

“HSIB places utmost importance on the need to ensure that rapid learning takes place for cases that fall within the eligibility criteria of HSIB's maternity investigation programme. There are several stages throughout HSIB investigations where the opportunity for identifying and addressing safety risks is provided to trusts, and these were implemented during the investigation of baby [the deceased]'s death. 1. It is HSIB policy that all NHS trusts are advised to complete 72-hour reports for cases that are”

“services, HSIB investigators also immediately escalate any safety concerns uncovered during the investigation process to the Head of Midwifery and Clinical Director. This case was discussed at our clinical panel at the outset of the investigation, which identified key lines of enquiry, but the panel did not identify any preliminary findings which suggested an immediate risk to patient safety. Through our regular engagement processes, we ensure that prompt actions are taken by trusts in response to any”

“HSIB held a roundtable review with SaSH Trust on 10 January 2019 which included a discussion of baby [the deceased]'s case. A summary letter was sent to the Head of Midwifery on the same day and outlined HSIB's concerns relating to staffing, escalation, interpretation services and debriefing.”

“Quarterly thematic reviews are also held with each trust where there are active investigations to share learning accruing from HSIB's maternity investigations across the country, alongside identifying themes for each organisation where there are particular areas of concern. HSIB held quarterly review meetings with SaSH Trust on 10 May 2019, 6 September 2019 and 6 December 2019.”

“increased midwifery staffing numbers by 10 full time equivalents and undertake a six monthly Board level review of midwifery staffing”