MM Day Two Part Three

your fingers okay everyone welcome back to day two afternoon session of monitoring May um we’re delightful to and really happy to introduce both Laura Sarah and jenily I’ll get you all in there who are going to talk us um to us they’re from the IFS uh and they’re going to talk about how they standardized all their training so after the conversations this morning uh it’s quite apt that this is the way that the morning is Flowing very uh unplanned or very well planned agenda that it’s all flowing together today so I’d like to hand over to the team from Over the Border in Wales uh to kick off this afternoon session so thank you thanks Sarah that’s uh great yeah it’s been can I just give you a big Round of Applause as well it’s been fantastic day and a half so far I really enjoyed I’ve dipped in and out but it’s been really really good so well done guys I’m just going to try and quickly share my screen okay so Jen go for it just tell me when you want me to move on lovely thank you H good afternoon everybody my name is Jenny Lee Harrison and I am the project or one of the project coordinators for ifs Wales and first of all we just want to say a massive thank you for um inviting us along today and allowing us to have some time to talk to you all um so myself and Lauren and Sarah are just going to talk to you a little bit about the work um of the ifs Wales program which as you can see on the first slide is an all Wales program of Education in feal monitoring and surveillance that has been rolled out across NHS Wales uh since October 23 thanks law um so we started doing this work we um were greatly aware that we were blessed by being in Wales we feel blessed by being in Wales anyway but we were blessed to know that we come under the umbrella and there’s quite a few things that um we managed to do in Wales on an all Wales basis and we appreciate that that isn’t always achievable anyway so when we’ve sort of extended and taken the program and promoted the program anywhere outside of Wales the first couple of things that you see are the typical questions that we get asked so first how have you um managed to collaborate and what has helped you to do this um and hopefully throughout the course of the presentation some of these questions will be answered and if you’ve got anything further to add then obviously just let us know so as I said the how um we were this work has initially um LED from the recommendation from Welsh government um due to the responses that we’ve seen um in costs implications um and obviously most importantly the harm that occurs to these families when um occur when when a harm does occur to a baby um so as a response to this Welsh government approached the Welsh RIS pool um who currently oversee other um safety and learning programs um and asked them if there could be a standardized program of Education put together um for Wales so that was sort of the the the lead and drive with that um we’re really fortunate in Wales that we have as I said some other all whales um initiatives and we all actually have to attend um a mandated prompt whales course so that was adopted from The Prompt maternity foundation in 2018 so um all midwives Obstetricians and obstetric anesthetists are mandated to attend a prompt course annually so the sort of um this practice was already taking place obviously in another field of education but an all day an all an all day stand ardized training package was in existence so we knew the framework was there so in some ways it was quite easy we we sort of see ifs Wales as prompt wales’s little sister coming along and and following in some of the footsteps so the how was sort of a bit easier to get to get past La sorry can you just flick back one for me because the second question so how has your collaboration led to a standardization so as I’m sure many of you uh can can imagine these things don’t just happen by the the say so and the thought of one person yes it was an initiative that was um led by the Welsh government taken on by the Welsh whol but a it’s a collaborative piece of work so a national team um has been um recruited which make up and represent a large proportion of the health boards in Wales um with a representation of both midwives and Obstetricians so again that collaboration coming together for the planning of work has led to the collaboration of the impact back to the work so the vision from the very beginning was that standardized all whales training program in intrapartum fetal surveillance aiming to improve outcomes for babies and families and I’m sure you know that has been the theme of the last couple of days with the monitor in May and I think it’s Central to to everything that we do isn’t it is that last part is improving the outcome so the vision was always quite clear I think about what we were trying to achieve it was just how we went about doing it thank you Lord um so those of you that aren’t familiar with our small but mighty nation um Wales is split by Seven health boards and within those healthboards are varying numbers of um uh obstetric units uh midr L settings and there’s just a breakdown coming up on the screen of just how many births that we do well for the 2022 um year there was just under 29,000 birs and there’s a little bit of a breakdown there that gives you an idea of um how they are separated one of the things that anybody that has traveled through Wales will realize though that although it may not seem that large actually the the commute and the journey around Wales um although it’s 177 miles from the furthest units apart I did this actually the other day and it took me closer to 5 hours so it must I must have not got as stuck as much traffic or whatnot on those days but it’s just to give you an idea that the although the collaboration may seem big in some ways and small in others actually geographically it’s absolutely enormous because we’re not always blessed with the lovely motorways as well so there’s quite a bit for us to take into consideration when we are sharing that work around and obviously making sure that the equity is there for um the patients for the women and the families that are coming within our services next l so we also have um in Wales the inpart and Fetal surveillance standards these have been um in circulation from 2018 when they were initially published and they have recently been revised um these have been overseen by the Strategic Wales maternity and neonatal Network um so they haven’t had they’re not anything to do with the program of Education that we provide in as much as we weren’t our national team weren’t involved in the development of these what we have done is written a program of Education that responds to these standards and allows each of the health boards to meet the standards as they were because as I said these standards have been in circulation for quite some time however when um myself and my colleague Beth came in to post as um coordinators one of our first tasks was um scoping the landscape about what existed and it was absolutely vast it took us a considerable amount of time as you can see Dot and all around that map to see how these standards that were pretty much as they are now they have been refined but as they were the interpretation of them was absolutely vast so that’s what we were to do was find that standardization so this these were the what these were what underpinned it um in particular number three and number four so um it just gives you a little bit of an idea about what we were aiming and this was sort of like our framework in order that we base the program around thanks l so particularly number four um is what we whenever we are and whenever we’ve been in any sort of development phases or planning phases for the program we’ve continuously come back to this so all midwives and obstetric doctors should attend a full day of multi-disciplinary training annually and the day should incorporate and you can see the list of below and I know that the one that has sort of been a little bit of a head scratch and a bone of contention for some people has been about the obstetric attendance um for the Ia part of the day um but I think it’s been quite pleasing to see throughout the roll out that’s that’s taken place since last year wherever we have maybe had um some Obstetricians that have maybe felt that it wasn’t necessary um by the end of it they’re usually in agreement that it was it was really worthwhile and taking place and it’s really pleasing to hear for lots of different reasons thank you l so as I said I Welsh rpol were approached by um from Welsh government and for those of you that are not um familiar really with the wsh risol wsh rpool is associated in um dealing with the large scale claims that come from NHS Wales and just to give you a little bit of an idea the um you can see on the screen there maternity services are the largest overall contributor to clinical negligence claims in NHS Wales and that was in 22 and there has been no difference in that in in 23 um and I I can’t imagine we’ll see a great deal of difference in that so far from the projection for 2024 um and whilst they only make up 177% it’s actually a third of the monetary value um and like we said in in uh the year that this was taken from it was up to £86 million in clinical NE and whilst we always say Obviously it is not about the financial implications for those family there does need to be thought given to how differently we could be spending that money and what the difference that that could be Mak into the NHS services and I think it’s something that we’re all aware of thanks law um so in the reviews of the cases that the W schwift schol um undertake these were the themes identified um and you can see a few there in bold which you know I I don’t think any part of that list is a surprise to absolutely anybody is it you know these are themes that we see day in day out in all the various reports that are being published um but the escalation the poor documentation that delay in acting you know these are all contributing to things not just not just in um obstetric emergencies but within the sector that we were looking at as well in terms of fetal surveillance thanks law so as I said it wasn’t um just one idea and one person’s team after um Beth and I did our scope we went out to recruitment um and we were really really overwhelmed there was when when we did IOP we we were shocked but not surprised I suppose in some ways of just the amazing work that was taking place in Wales and the absolute passion and drive of individuals to be inter to be improving um the outcomes within their service and what we were really lucky to do is we were able to bring a group of clinicians together that embodied this passion and had this knowledge base so you can see um the bottom make faces there they are the the people people that have written the program and they are the ones that have had the the greatest input into making sure that what we deliver nationally is to the highest possible standard we were given purple tops um much to the dismay of some of our colleagues who absolutely can’t stand the color but we are really proud of our Pur so uh yes and then so our aims so some of these we recognize to be highly ambitious um but actually looking at number one you know it was that implementation of an all whales training program which meets the standards which is obviously what I’ve just talked you through and then comes the real nitty-gritty then comes the um the the big aims and the big hopes for for what we had what we hope to achieve with the program so um to reduce the preventable neonatal brain injury and still birth uh to reduce unnecessary intervention for non-hypoxic babies and to reduce the claims profile associated with avoidable harm related to inart and feal surveillance than do you want to come in there Lord do you want me to yeah I think this is me got multitask now and put my own slides on this is gonna be fun thank you um so yeah hello everybody my name is Laura little as Jenny is kindly introduced I I’m part of the ifs Wales national team and I am the senior Midwife of fetal surveillance in kumt Magano if you can remember that’s towards the the southern part of Wales so we were developing our training we came together literally this time last year and the plan was um because uh a health boards was started starting their training program for the year in SE September October that was kind of our deadline so it was quite um a full-on few months that we had all together but somehow we managed to do it um but as you can imagine and as I know that there’ll be lots of people on here how do you keep your training sort of interest in you know how do you make it so it’s not just a tick boox exercise which we’ve talked about this morning on different um conversations that kind of thing so it was trying to make it interactive um and as the standard says it has to be multidisciplinary and I think we all recognize the importance of that um um whether we use scenarios and Does it include human factors and there’s been some really really interesting talks through monitor May about human factors uh and one of the colleagues in our team uh Fran she’s um doing her Masters currently in the human factor so it’s really brought a lot from everything she’s seen elsewhere and and is learning about into this uh program so just to give you an example what our day looks like it is quite full-on and uh and packed but we think it’s really important to try and include all of these elements not just for the standards but it just gives all of the background to all the delegates that ATT attend of um you know what it’s got to do with fetal monitoring and why they’ve got to be there basically um so at the beginning of the day we do that introduction of why why ifs Wales and basically what that sort of does is talks about all the work that Jen and Beth did when they went out and did their scoping and makes reference to the fact that even in Wales which appears small in terms of health boards and only being seven healthboards there was a huge diverse array of training and you know things that were going on so there was no standard and and as we know we’ve talked about human factors there’s a lot of movement between healthboards doctors doing their rotations midwives moving that kind of thing and when you get there you get to your labor Ward and you think oh I’ve got to learn how to do this interpretation tool now or what have you that kind of thing so we haven’t managed to get to that point yet but what we thought is we could make this is our you know our standard to begin with this is where we start kind of thing and make sure that the training that’s delivered is standardized um so as you can see it’s broken down into chapter format covering all those um aspects of the all whale standards as Jen made reference to so what we do when we’ve done the why we split into we talk about the human factors and to try and you know get everybody live and DEP and what have you we split them into groups of six and we give each of those groups a esar and we did actually trial list when if anybody was at the Bix conference we did do it there um and what we do is ask we would like you to report back your level of concern following the discussion so all the groups are presented with the same ctg which is this ctg and they’re given an esar and they’re asked to have a few minutes of conversation and then feedback to us their level of concern from uh on a grade of 1 to 10 one being they’re not concerned 10 they’re extremely concerned uh and feed it back to us as a whole group then so what they don’t actually know is when they start feeding back is that group one over in the corner gives us oh two or a three and yet group run um group two in the front is sort of what what’s going on what you mean I’m I’m really concerned that This Woman’s going to theater you know that kind of thing so basically it’s a little way of introducing that it’s all about the context so each of those groups has actually got a different SAR but they’re unaware of it so it was just a way of sort of highlighting how context is really important just poking a ctg under somebody’s nose isn’t good enough it doesn’t give the background and what have you but it seems to be working really well in the training days and we quite often when it works well you get that ah moment you know from all the different groups when it sort of starts to make sense because what we do is ask them then to read out their Asar so it sort of the dawns on them kind of thing so it’s a really good way of sort of livening things up first thing in the morning throughout the program then we like to focus on different elements um obviously the the great emphasis on birth choices making sure that women are informed of their options and what’s available so we use these stamps throughout the presentations to sort of bring the focus back to these different topics um when we talk about the physiology and that kind of thing we sort of try and prompt that people you know come up with a diagnosis whether that diagnosis ends up being correct or not doesn’t really matter but it just helps in the escalation um again everybody’s more than familiar with the house the baby and obviously the human factors elements we do use the tools that everybody again on the call is very familiar with and this is obviously quite new to Wales and we sort of it’s help embed it and particularly because we have our uh relationship with the prompt Wales team as well it’s sort of it’s another way of embedding it across across the the learning environment so um we display the posters in the area and we talk about it for um a period of time when we use scenarios and that kind of thing as well so one other concept we do just to try and make things a bit different is towards the end of the day is one of our Obstetricians it’s part of the national team um came up with the concept of the labor W board so how it works is that we use different cases and this can be cases that each Health Board individually has perhaps been given the action to share the learning as a result of um you know National recommend report recommendations that kind of thing um it’s it’s sort of an opportunity to do that if you like um and then we create a labor W board so each Health Board will create their own so they can feedback that learning um and anonymize the cases that kind of thing and what it helps to do is talk about things like all the human factors and the escalation and that kind of thing and we’ve read them out you know kind of give the the initial esar if you like of what’s going on in room three and then there’s something going on on the mlu and blah blah blah blah blah and it’s sort of looking at the um obstetric colleagues in the room and sort of saying well what’s your priority where are you going to go first kind of thing and it also helps Our Midwives to understand when they’re shut away in room three what else is going on in The Wider world because we’re all very aware that that’s often what happens that you’re you know cornered away and you don’t know everything else so when you’re asking for help you know it it’s it sort of gives you that awareness basically of of what the MDT is up against so it it’s worked well and it’s been adapted and um adopted in different ways um and the teams have sort of done it differently but uh yeah it’s a good concept we think and one of our colleagues is making contact with somebody who has AI skills so the future may look quite different and we we want to make it really interactive but that’s a little bit down the road I think just yet but uh it’s on the cards so uh yeah so this is it then so when we go into each of the rooms we give a little summary of the the ctg and the care and that kind of thing we give the background of the you know what’s been going on anti-at with each of the ladies um and obviously what we make sure that we do is sort of get in touch with any of the staff beforehand to let them know that these cases are going to be used in learning and we also make sure that on the study day that we give that disclaimer that you know people are really mindful of their Civility and the language they use and that and this is not about oh what why did they do that that way or you know it’s this is about learning and sharing learning and helping bring all that we’ve learned back together at the end of the day so we use little icons and we talk about our escalation and the use of Aid um and we sort of have little practice runs of that also try and deafen you with that so I’m now going to hand over to my colleague Sarah oh afternoon everybody um my name is Sarah Davis I’m the fetal surveillance Midwife um in cardian Vale the University Health Board which again is South Wales um so this this sort of section is just um looking at where we’re going where we’re going from now so we’ve done a you know I think we’ve done a great job we’ve got our program together we’re delivering it we’re getting positive feedback we’re making slight adaptations to our colleagues feedback but I suppose um one of the big questions that we’ve been asked is is our guidance approach to um interpretation so um next slide please Laura to to go back to that to answer that question oh my box looks that looks very funny you go um it go to go back to the standards so standard two of our old Wales FAL surveillance standard says that any health board can use so it should be based on physiology but they can use any standard interpretation guideline so that could be nice fego or physiological so that’s um that’s something that needs to be considered so uh next slide please Laura so just on the next slide is an EXA two examples of the tools that are used in Wales so the tool on the left hand side um is used at a Health Board who have been practicing physiological interpretation for about 15 years um and then the other slide is um a Health Board that are using the prompt it’s a prompt sticker which is an amalgamation of um nice and Figo so you can see there’s quite a difference um and and for those that do physiological interpretation we we know that you will come up with a different answer to to a guideline often when you’re using ifys interpretation so obviously that can be that potentially is is an issue isn’t it because we’re teaching physiological but actually our colleagues um are using another tool so there’s been a lot of discussion around that and um historically there was there’s been a lot of discussion and no agreement could be c um was made on that however we probably do need to go there again because um because we have this inconsistency now for our for our colleagues um so basically I suppose you can use an analogy of you’ve got a new piece equipment so it could be a a pump for example so do you do the training the pump training first and then introduce the pump or do you introduce the pump and then do the training so I think we’ve sort of taken the approach that you do the training first and you introduce the tool so going forward having sort of established our our training day we’re now going to be thinking about how we develop the interpretation tool for all whales to assist all our colleagues so that we’re all ideally on the same page andan obviously what we need to be mindful for people transitioning from nice or Figo guideline where it’s very sort of um almost prescriptive to this more sort of freelance approach is is quite a big step we and we certainly our Health Board went through it um a number of years ago so we just need to be mindful of that and obviously we can’t expect people to to run before they can walk so we need to be thinking about a tool that’s going to support our colleagues in that so that’s some work that’s going to be ongoing over the next year or so thanks Laura next slide um so what’s what risk assessment um the sort of labor so this was another question that we’ve been asked historically next slide please Laura so this slide you probably um again if you’re doing physiological interpretation you’re aware of this slide so this is um this is what we recommend during our section on anti-natal um physiology so we’re talking about you know whether or not the baby’s fit for labor so just those those physiological aspects um next slide please Laura and again as we were talking earlier we have these we have these stamps so again we’re always talking about it’s not about the ctg but it’s actually about the baby um next slide so that’s that would be for using a ctg so as um as Jenny Le was saying we’re quite unique we’re Wales we’re very unique um we have we also have an what’s called an all Wales clinical pathway for normal labber so actually which this this document is used throughout Wales um on our midy lead units and well our sell lead units as well for um IIA um and actually so our risk assessment that the the slide I showed you before is about about sort of cggg usage but actually this this document has a risk assessment at the beginning where it asks the Midwife to sit with the woman spend time um confirming feal movements osculating acceleration establishing the Baseline etc etc so actually we have we do have a very sort of robust uh document for that assessment um in our low-risk um population of women next slide thanks law um what have you implemented um in the mlc around fresh eyes and ears so this is an interesting one so again going back to the all Wales Care pathway um actually go to the next slide this is in response to the standard so that in the standard it talks about the fact that we should be performing um holistic reviews of our our women on an hourly basis so it doesn’t explicitly say that should be around the fal heart but of course it would include the fal heart and it doesn’t explicitly say um that it should include a second person but it gives us the opportunity to make that about a second person so there is sort of guidance but it’s not explicit but it is therefore um interpretation next slide please SL yeah yeah um I I just um caught the end of the um commy assessment uh discussion actually because actually in Wales we don’t have a compy assessment and again it’s another thing that’s been a lot of um discussion around and I think it’s that it’s that balance isn’t it between is it an assessment or is it an opportunity for for people to say this is this is areas where I need some support and strengthen around my knowledge Etc so we haven’t gone there yet um whether or not we will go there is is another question but we have we’re not there yet and I don’t think that’s on our plans for the next s of 12 months 12 to 18 months um and as as Jen was saying me our um clinicians move around from different Health boards so um again have we got a passport will actually be we’ve got a standardized program now we know that if a clinician has attended the session in their Health Board it will be standard and it will it will actually translate to the next Health Port so actually we don’t we don’t have a training passport because actually once we know anybody has um attended that day then actually their their their training standard and includes all the things that are on that on that Welsh that Welsh standard um so where next so basically as we said it’s where it’s basically um continuing continuing the work that we’re doing already but basically you know um it’s all very Dynamic isn’t it so actually in response to feedback we’ll change the day um in response to other clinician comments we might say develop the tool um for interpretation Etc so it’s it doesn’t stop you know once we put the DAT together it hasn’t stopped there and it will continue to um to develop and those those are some pictures those some pictures of our days I think yes so I think that’s it thank you yeah this is just us doing the faculty training days um when we were centralized in Cardiff so this was just bringing on board that it’s not about us going around and doing all the teaching we’ve trained faculty to be able to facilitate it in each Health Board so uh these were just some of the initial ones thank you no thank you because you know I’m very passionate about this and if only we could just do this in the UK would be so much easier um but uh so what you’ve achieved um in your small But Mighty country is is amazing and I think everyone will probably agree you know I like it over the border so I’m I’m I’m there with you um anybody got any uh questions for the team I mean I think they probably answered it all during their presentation to be fair but has anybody got anything they’d like to ask uh sisa uh yeah hi sorry I’m feeling very vocal today um uh what do you do for an is that also incorporated into your day it was one of the first questions that we got asked wasn’t it when we started scoping was why is this ifs inar fial surveillance and basically we’ve taken our name from the standards that were already written but yeah there is um a chapter on antinal physiology where you know I mean the girls can probably articulate it a little bit better but we go back to basics on everything we’ve sort of seen year one as one of the things that we were mindful of is that lots of over the seven house boards they were all in different positions starting off with their training because you know some of the units have been blessed to have like lauras and Saras within them that were doing their training already whereas some were just were still doing like computerized packages so what we’ve had to do is make sure that year one sort of fits for everybody taking maybe a couple of steps back for some and a couple of steps forward for another so yeah it’s got antinal in there because it has to we go back to basics on everything um it sounds amazing um uh what’s your plans for refresh you know like if everyone’s doing it every year they want to be saying the same thing so sorry do you want to come in sir yeah I was just gonna say so yes so we’re already planning next year we’re already having meetings around that so there’ll be some sort of fundamentals that will stay the same so I think I think you can never hear Too Many Many times that sort of Mantra about physiology and just reminding people particularly because you have a varied audience so some people won’t be doing it all the time obviously making it making it translate because I think it always seems to be about ctgs but it’s not all about ctgs as well it’s about physiology you know so basically that translates to wherever this woman and her baby are Yeah so basically we are yeah we are ref refreshing it now but keeping you know quite a few of the sort of fundamentals around physiology and I think what we’re Le to do is sorry it’s willing to keep you one sort of in an archive so if you’ve got any new staffs that come in or if you’ve got people that want to refresher that will always exist and this is like the next step to it so my colleague Beth and I work permanently on this whereas the rest of the team are sort of on a bank um basis that we can dip into them so as we support all of the health boards day and day out with the implementation of the support obviously we draw on the team then to be our eyes and ears about the developments and the changes that we need to keep the program fresh every year wow um would you mind last question sorry would you would you mind if I came and uh maybe I can see in our um we’ve got a team group and I know um Mr Haram one of our um consultant obser ticians is also on the call today and he’s just actually put in the group you know we should be inviting whoever wants to come along so these days um take place um in six out of seven of the health boards so one of our health boards doesn’t have any obstetric units within it they feed into I think it’s 11 dgh is it’s something wild like that some are in England some are in Wales so their midwives come into their neighboring Health fors to to have the training even though they may not be using ctgs obviously we know the training is so much more than that so yeah these these days are running at least five times a month across NHS Wales and yeah there there will always be space if anybody would like to come and see we don’t promote that it’s used on teams it is we do it has been written for a face to-face element um and I appreciate that some of you are maybe a little bit further away so for the the possibility if you needed to teams in we could maybe see about that but you know we’d always invite you to Wales to come and see us and maybe a bit of sunshine the only issue might be is through the medium with Welsh obviously but other than that it’d be fine ladies and gents come on and there’ be lots of caching involved we lots of cutes only only only joking I’m there you’ve got me already Katherine there’s a road trip going on our um I can put our um team’s email address into the chat bar so if anybody following up from this wants to get in touch please you know drop us an email we’re always really open and welcome to to hear from other people and sharing what we can do to help them support you thank you great to hear from you and all the fabulous work you’re doing thank you so much move usly on though now that’s okay um and next up we have an Antonia Jiva who’s going to talk now about using electronic patient records to improve assessment and maternity triage so Antonia it is a delight to welcome you back so I think hello thank you very much for having us today can you hear me and can you see the slides okay I stopped being able to hear Katherine very well but thank you for the lovely introduction which I assume was lovely so let me just say that it’s my absolute pleasure to be here again I’ve really enjoyed as much as I was able to catch in the past um two days day and a half uh as usual fantastic job a real pleasure really humbling to see all of the work and all the positivity that it’s happening across uh the UK so just kind of a quick update from what what we are doing at our end in Oxford uh which is bit different um than your end and I’m joined today by uh three lovely team members that are going to make an appearance and say a few words as well so it won’t be ow me um so um we are based at the University of Oxford uh so far we’ve been predominantly research based uh this is our web page where you can learn more about what we are doing um it’s large team uh by now behind in different forums Partners collaborators we are very well funded by DNR and we’ve had funds through epsrc so these are different engineering funding bodies and we were funded originally by action medical research at some point as well which is a very good charity in our domain um overall in principle we work very well here with the um our trust obviously so we are embedded in the uh maternity trust in the hospital at Oxford so we work uh we’re very multidisciplinar and we are committed to bring Technologies basically to improve the situation around labor monitoring of Fe the fetus not the mom necessarily is as far as I’m concerned um and we have a growing uh Team of collaborating hospitals that I wanted to mention here uh four of them in different capacity either harnessing the data or doing first visibility tests uh of our tools and I’ll talk to you a bit more about it we do have quite a lot of international collaborations and I highlight just the main ones here so this is part of our team we are happy people uh here in Oxford we’ll have uh uh the three team members uh make an appearance and this is uh part of us on our last 14 te meeting few weeks ago which I find funny that’s why I like to show so everybody here knows this uh but I’d like to highlight it again that actually the technology is really Limited in what we are trying all to achieve uh and uh yes there are a lot of uh things that need to be improved and all of you are doing uh your absolute best and a lot of us are but I just wanted to put this as a humble reminder here that in reality we do not have the technology to tell us how is the fetus doing inside uh in particular throughout the Colossal process which is labor for a fetus as well all of the complexity of the physiology that surrounds that and the sheer lack of ability to be a lack of technology to be able to say okay is this baby getting enough oxygen is this baby infected is this baby in neutral right having um placental insufficiency it’s we’re still very limited so I just wanted to highlight this and uh the Oxford labor monitoring team is our commitment longer term as well to you know bring any to in the tool boox possible to improve the situation from technology point of view so that then it much could be much more easy or for midwives and doctors to do their job if we actually had the technology to tell us what’s happening it’s a long journey it’s very difficult because of the physiological complexities but it’s also very few people in the world working in this domain which is a problem I think um so I always say that so I’m basically a a scientific child of Chris Redmond who you know from those Redman and placenta research but on the side he actually did uh set me up and trained me originally from 2007 here at Oxford entirely focusing on labor yeah so he had the vision already in the ’90s to start curating in digital format all of the cages and all of the maternity data and all of the outcomes uh at Oxford and that’s what facilitated the do Redmond building but it’s also what uh I had to deal with so we sit on a internationally World leading massive database of uh digital cges with clinical data and that’s what I’ve been doing in the past um many many years um so we are uh working throughout uh in as I said with every twool box to provide better technology so there’s quite a few different projects but what we are here to talk to you about is the fitful labor to which is our most advanced close to the clinic too um and some of you have heard me talk about it already maybe to death in the past few years so it piggy back so it’s a software it’s a decision support Tool uh similar to do Redmond uh it takes ctg data from uh the existing monitors we’ve put it on a tablet wirelessly uh and I’ll show you some photos around it it takes clinical risk factors so assesses the ctg in the context of maternal and fetto risk factors pregnancy and labor factors this is what is in at the moment but we are extending this and there are limitations of what we can put in and what we can’t but this is the first beginning so it’s the first prototype so to say and then uh the fitful labor in particular is focusing at the onset of Labor uh so it’s a shortterm uh up to 60 Minute um assessment so the ctg is running uh up to 60 minutes and there is a report that puts the risks in the context of the population data that’s going into the device so converts it to percentages at the moment um there caveats to that so this is our current uh risk display too and this is our clinical research fellow doing feasibility study at Oxford uh and this is how it works at the moment wirelessly it captures the data from badgernet because we have badgernet at Oxford at moment um and actually pre-populates this things at the moment from badgernet but it’s a standalone T standard tablet on which the software runs um and you can see any room in the hospital at the moment uh but obviously we should be using it in triage uh but at the moment you could use it um as well on the levels um this software of course could be integrated in the future in the budger net epr system or in other epr system so ideally sits on the same screen that you use for all the other epr activities but at the moment for research purposes and for a number of reasons is on a tablet so just to summarize a little bit as so it’s around the onset of Labor the idea is to triage and to risk assess at that point flu the very rare out babies for which there is immediate danger and escalate and help with the escalation majority of the cases reassure um that uh everything seems fine from from the perspective of the two which is CG and the clinical risk factors of course there is a holistic approach that needs to be taken similarly to those Redmond it’s to advise it’s to support uh it is not to replace and there’s many things that you cannot assess with this kind of tool so midwives and doctors still need to use their overall clinical assessment but it is to streamline and make things um Based on data and more objective um the onset of Labor is to Define as we know so for practical reasons after quite a lot of discussions including Chris Redman and um all the researchers on the do Redman side but also of the researchers at our side at the labor monitoring within our Hospital including our clinical leads uh We’ve concluded that basically fitful labors comes when those Redman cannot be applied anymore when you have a query of Labor when you’re having inductions ongoing so when you have contractions so that’s the right but because of the data that’s gone into it actually it’s valid up to five hours because the date you used up to 5 hours since the clinical onset of Labor which with the caveat that it’s not defined uh very well um so it takes CG clinical risk factors it’s actually trained to provide the risk for severe compromise it’s not looking for a cmia necessarily um and severe compromise and there’s lots of caveats around that uh includes all these kind of hard outcomes and in particular he’s looking to spot the vulnerable fetus that is already either compromised or a diminished reserve the one that it’s not having good cyclicity in the heart rate but also combine these risk factors when we know okay but the maternal temperature is a bit increased or it’s a firsttime baby to an older mom these kind of things that we know are risk factors not to mention thick meconium but how do they join together yeah so if the membranes are ruptured T and there is stonum that would definitely be very important so uh there’s been a lot of work around how how risk is communicated this is ongoing it’s not fine now it’s a big thing actually and Mariana is going to talk about it more I just want to mention one thing before I pass on to Mariana the clinical fellow who’s doing the usability um is that so this is based now on 51,000 prior birds in Oxford these are our accuracy it will become published and at some point you know distributed at the moment it’s still inhouse but ultimately what we’re looking is to provide very early warning at um at least 10 11% we are estimating probably more of the severely compromised baby is at the end of birth and you’re looking at 10 to 15 hours earlier warning at the same time we’re capping very very we’re controlling the force positive rate very carefully because you cannot have a very high Force positive rate and this can be controlled with data and that’s my last message I think but is that you know when you have a lot of data in you’re training this tools you can publish it and it will come with known false positive rate and you will be able to control this through your escalation Pathways as well when is it called red and what do you do with that and I heard lot of talks yesterday around those redmen that problem of how do we escalate well okay you have a measurement of something you have a score you have a number what do you do with that so we’re putting a lot of work um that I think need to come out with that two one day when it’s ready with that escalation pathway and um it can vary as we know in each Hospital there is a lot of that element of how do you design your own clinical escalation pathway for each two where it’s a ctg where it’s dose Redmond where it’s blood pressure but we will try to come to bring this uh to uh to to the clinic with with kind of uh databased advised escalation pathway anyway I’ll shout up around these things and I’ll pass on to Mariana um I’ll flip the slides for her I think uh so um just let me know yeah sure thank you thank you Antonia so I’m Mariana I’m the clinical research fellow that is developing and implementing the fit for labor and I’m also a second year PhD student and my background is being an obstetrician so in the next few minutes I’m just going to tell you a little bit more about the usability testing that we have completed now at Oxford and a little bit about our feasibility study that we are currently currently recruiting at the John Rod Cliff so uh one of our priorities uh since the beginning uh when we were creating the feed for labor was uh to make sure we place the user in the center of all our design so the user meaning The Midwives and the doctors that will be using the tool um so from the beginning we we decided that we needed to do visability testing and for the majority of you that if you have developed any website device or tool you know how important visability testing um is in terms of uh testing and evaluating the overall uh user experience of how easy is to perform a task of the tool that you uh developed so it’s a fantastic opportunity to get in a very short period of time um to get very large amount of feedback and also to discover problems and fult with your uh tool so this is the picture that you can see um is the six sessions that we organized uh so far I was together and I’ve been working together with the experimental psychologist to help us navigate through all of this and uh we had doctors we had midwives we wanted to have a a bit of different seniorities and different age gaps um and all of this was done in a controlled environment uh and we gave them a lot of tea coffee to make sure they’re comfortable in Sharing what their honest views and opinions about The Tool uh were um and uh Anton if you click again you can see just the number of yes perfect the number of clinicians that we already uh run this um sessions and we think we achieved data situation around uh our session number five when there was no longer a lot of new ideas and new point of views and um we we thought this is a good number so at the moment we have completed them at Oxford next slide please so just a little bit more about the sessions um we’ve been running them always in the same way a kind of a structure uh approach uh to make sure we decrease by as massim as we can we all start with an introduction we have a pre-recorded video that is me um over there a little bit pregnant um explaining the the the fit for labor but not exactly how it works in terms of completing tasks because that’s what we wanted to test the participants uh achieving and we gave them four scenarios you can see on the bottom end uh each gets a bit more complex as the the session moves on and we tell them we are not helping you in terms of uh finishing your tasks if you can’t move forward is actually very useful for us to know why just make notes and then move forward to the next scenario and if each uh after each scenario we always give them a seq which is a single leas question questionnaire and a su questionnaire which is uh called system usability uh scale questionnaire that is very used um uh in the industry whenever you design any tool or website we then finish up with a focus group which normally lasted we say 30 minutes but um midwives and doctors they had a lot to say about this so we all is overrun in all the sessions and then we ended up with uh a conclusion in the end uh next slide please so this is just one of the one of the results we got we we have a lot of things from these sessions but one that is potentially interesting to see and during this presentation is the results of the SS uh questionnaire so the Su questionnaire if you don’t know it’s a 10 question questionnaire that you scale from one which is strongly disagree to five which is strongly agree and you generate a score from zero to 100 and higher score signify better usability uh so if you have a threshold of 68 is above average performance and if it is above 80 is suggest that is excellent whatever product you have um there’s a very high chance that you would um uh recommend to your colleagues so we started our first session uh with a a good result I would say it was 77.5 is the blue the light blue era that you see over there and after that session they gave us so many things to do and so much work was generated and so many problems that after spending many weeks even before we couldn’t even find all these things that they told us so we Chang a lot the tool we Chang and we improved it we correct a lot of things and going back again on another session actually our Su score went from 77.5 to 80 5.8 which is actually on the excellent um part of the of the scoring so it’s it’s quite good to see that our work paid off and people are now in a point that after repeating inability sessions in maintain all is above 80 showing that the tool is potentially that point that is actually ready to be used um in our CL clinical setting next slide please so the next slide is just one example of things that we get from doing these sessions um as Antonio showed the techical pathway uh on the right side is how we communicate the the risk which it seems very simple at the moment when you look at it but there’s a lot of thought a lot of discussions went on um to get to where we are at the moment um so we try to get into a kind of a Lismore approach to use Simple language uh numbers uh one of the feedbacks that we get um was uh that we got was to use caller people like Cola uh Cola speaks to tired brains but there’s also a lot of people that don’t love color because of other reasons in terms of it’s already being Diagnostic and this is not the point at the moment of the tool um also we wanted to make sure we had uh percentage and to have Graphics because some people prefer to see the risk in terms of comparison to others others prefer to see it in a graphic that’s why we have both things over there uh you have softer angles and edges one of the feedbacks that we got from the sessions was um The Midwives sometimes weren’t sure how to communicate this so we added that button there that says communication guidelines or whatever Coler you get you can have a quick read before speaking to a patient in terms of how do I communicate this next slide please so the next slide it will show you what we got from the audio transcriptions this is our coding of our qualitative data so there’s hours and hours of our transcription and three of us got together and did this analysis and you can see the we grouped them as um uh in COD so uh the comments and the the the time that they spend speaking about a certain uh issue we group them into codes and we divided between the midwives and the doctors and some of the topics they came up on this focus group um they were very similar for example just um I’ll give you an example one of the things that they come up was escalation for midwives um The Midwives uh spend a lot of time saying that this tool could potentially be very good if you are a very Junior Midwife to give you confidence to speak up um also would help um the effective uh Midwife doctor communication which sometimes the doctors uh don’t come when the The Midwives are worried about patients and on the side of the doctors what they said this would be very good for them because sometimes they don’t understand how quickly they want a midw they want the doctors to come uh when they are called so this if you would say I have a red uh risk or I have a very high risk here please come and they would understand the urgency of of that um next slide please so my next two slides are just a little bit about other part of work that I’ve been doing which is our feasibility uh study so we started for the first time testing this tool in a uh in real patient laboring and with clinical staff working so our feasibility study um started um uh a year and a half ago there was a lot of issues a lot of problems with honorary contracts and uh things like that but now we are recruiting fullon and what we are evaluating here is the feasibility in terms of how practical and viable is to have the feed for labor um being used in a delivery Suite in a triage or in a induction Bay of course we want to see other things not just that we want to look into technical problems assessing how easy is to recruit how open the patients are to um to this decision support tool and we want to get as Max the maximum feedback that we can from the staff and on the side I just included uh our inclusion criteria that you may be thinking who do we want at the moment we are recruiting above 36 weeks single turn and early stage of Labor as Antonia said so we’re not very picky we take the majority of people in early stage of Labor that needs a ctg so is this is people that need a ctg we’re not adding any uh workload to The Midwives next slide please and it will be my last SL slide is just for you to have an idea what are we going to do next so at the moment we are recruiting in Oxford we have those 23 patients recruited already we continue every time to improve the tool whenever we see any bugs any problems we keep improving it and what we are doing next and hopefully in the next few weeks um is looking very positive to start recruiting in stokan Ville in Asbury and in Birmingham we would like to recruit 30 patients in each place um and the main thing is to see in tertiary hospitals and in small hospitals um does it actually make a difference in terms of culture uh of Staff experience uh and patient characteristics how open they are to a tool like this thank you thank you very much Mariana for that whistle uh uh T around and next is Veronica Veronica introduce your hi everyone hi yeah sorry I’m Veronica my Midwife and a PhD a student in digital Health at the University of Bristol and building on uh Marian Antonia and the rest of the team’s work um I come up with the research questions if if you can click right hand click so this is my uh PhD research question so uh should we be using ethnicity and other social determinance of Health in these uh tools to personalize risk because we know that women from the private areas women with you know from um ethnic minoriti uh backgrounds do they they have increased um mortality um rights they have a poor experiences of care and they have worse outcom so it’s about should we be using this uh these variables uh to support the um clinical decision making so if you can right hand click so um this is just to show you briefly what uh the areas that you know included my PhD so have human computer interaction I’m supported by uh my uh supervisors in the University of Bristol then Ai and data science side of things is Antonia and Luba and then um Professor sorry Dr natal darkcoin um Lester she’s uh providing that part of the sociology aspect um and the next slide please is just about showing what I’m currently doing so um I’m currently uh I have undertaken interviews with midwives student midwives and doctors about potential sources of biases when we are um undertaking those um judgments around um CDG monitoring the decision- making processes and the influence of non-clinical factors that it has on on those decision- making processes um I’m also undertaking a um participatory um project with women from um um ethnic minority groups is just to uh check the acceptability of using that those kind kind of um Technologies to support to support in them in labor and also how can we make women uh you know accessible research for these women as well if they want to participate in that this kind of research um and just the last one so I’m also trying to um as well look at things from that data uh side of things I’m also learning um tackling all these research questions from the data side of things um so yeah it’s kind of like a mixed methods approach to tackle from different different sites and I would be grateful if anybody’s interested in this topic please get in touch that’s my LinkedIn QR code so that would be great thank you thank you excellent Veronica and now on the data aspect I’m going to pass on straight to the data person um hi everyone so I’m L I’m a data scientist U by a training and what I’m interested in is thinking about clinical risk factors so the the routinely collected data that Antonio referred to earlier and how we incorporate that data into risk ass ment tools and as anonia mentioned earlier uh fit for labor um was trained on a lot of data that was collected here in Oxford um and that is sort of booking data about the pregnancy and then all of the delivery information so was the uh woman induced how did she delivered and then information about what happened to the baby after it was born and this data set that we use in Oxford so here I’m showing you data from uh just Singleton uh Singleton pregnancies that were uh 6 weeks and over and ctg monitored um and that data kind of has varied over time partly because the demographics of the women who come in to give birth has changed over the last 30 years um and also because clinical practice has changed and interestingly also because software assistance have changed and the way we record the data into electronic patient records has changed um and we have to take that into account when we do this all risk assessment um analysis because we want what we want to do is provide tools that are kind of relevant today um and they’re sort of agnostic of all of these bits of say software and infrastructure that have changed um but in addition to data that we collect here in Oxford we hope that our risk assessment tools also translate outside of Oxford and can be uh later validated as anony and Mariana mentioned in other hospitals um and we have collaborations from uh Cambridge and now Birmingham so that’s uh s Su um and St George is in London um that’s Austin um who’ve um lent us some of their clinical data and ctg data that we the part of my job has been to standardize um and make sure that we can compare um what the labor data we have in Oxford and how it Compares with Cambridge and St George’s So currently we maintain this data set the uh of about 140,000 ctg monitor deliveries that spans the last 30 years um and for each of those we’ll have somewhere between maybe 35 and 55 different clinical variables um the relate to kind of booking labor and outcome next slide please um and one of the things that we can do uh with this data is that we can compare them so even though for example the the way that uh diabetes is screen for and defined uh in the different hospital trust NHS trusts um you can see kind of how actually we can look at over time and we can see that our um diabetes rates have increased over time so there’s any diabetes in pregnancy not um uh and you can see the three um hospitals Oxford and blue Cambridge and yellow and St George is in green um and this rapid increase um matches what we see in statistics published by the ons um uh matches across the three hospitals despite those hospitals having kind of quite different demographics within them um and the increase that we see over time is partly uh due to the fact that we do have higher prevalence of diabetes Now um uh but we also screen for it in a much more systematic way so we pick up more of it um and that’s important as we think about diabetes in pregnancy as a risk factor in pregnancy because if you think about cases of diabetes that would have been diagnosed in the early 90s there were just kind of clinically those would have been um ladies who were really unwell who were very obviously diagnosed rather than just someone who has picked up due to routine screening in 2021 say right um and so we have to kind of keep those um those changes in what risk factors mean over time as well into account um next slide please um and the reason we do all of this work is as anoria mentioned is because we trying to assess the risk for the severe compromise um a measure that she mentioned earlier um and we can also see how that has changed over time but it hasn’t necessarily go down in this kind of straightforward fashion that we might wanted to so you can see in Oxford in the um early to mid 90s it was much higher and uh that reduction we think that we see from that period is actually the standardization of of offering induction uh at 42 weeks um think has brought those L those um rates down um and since then we’re kind of um we’re sort of hovering just below 1% um the raise we see around 20134 has to do in Oxford has to do with um the Software System changing um and so the our data records kind of changed a little bit so it’s a feature of the data rather than a genuine change that happened clinically um and um in St George’s and in Cambridge we see slightly lower rates in part because the systems that they use are a little bit different so we have a little bit more missing data um there which means that we are not kind of convinced that we’ve picked up on all of the cases of severe compromise that that we would have um and um I guess that’s it for me so this is the sort of when we think about that infrastructure that goes into model building and how we think about can we identify lowrisk and high-risk pregnancies uh the message I want to leave you with is that this is very much something that does depend on like those little things of like oh how do we keep the data records and can we take a tool that was developed in Oxford with search and software systems to others and we think we can I think um thank you very much thank you very much and I’ll just speak back on this conclude I appreciate we we started a bit later but we are running out of time now so we would be very keen to hear questions and comments so I’ll try to shut up but I’ll say that this is um really the important part uh here as well is that um we can control the force positive rate and I don’t think we’ve seen this before and you I don’t think you have seen this before uh and this will come out published as I said in the right moment after it’s been validated with the right data and once there is a certain Protections in place and you know where people will be able to see what the sensitivity is what the specific what a certain number specific the force positive rate and so on and when you talk about all of the things that go in the equation or in the in this estimates uh you know the the mo the tools need to be validated on external Data before they are switched on in each Hospital ideally as well so before you switch it on in St George’s you want to have looked at the last year let’s say and tested your model and made sure it works for it before you actually switch it on but um a few slides here in the interest of time I’ve put if you want to see relevant Publications these are all around um acceptance of these kind of tools data driven tools um in the longer term future AI as well we do work on that uh but I’m not going to focus today uh some more Publications and these are some that have just been submitted this is a very interesting review that my student Amy um LED and uh it’s it’s coming out hopefully in BJ uh well we don’t know uh that’s where it’s submitted in the next month um we are also internationally you know trying to kind of move the field and uh Katherine uh this year we are going to Italy so if you’re interested the program is still I’m drafting the program so I’m very slow uh but it’s going to come out uh soon so this is kind of uh with the funny name we came with signal processing and monitoring in Labor uh so do have a look at that and just in the last 30 seconds or so I wanted to say is that you know where we are now in particular with fiful labor if we focus on that part of our research you know we have good evidence from data on the bench you know from retrospective analysis we have good evidence now from usability sessions that we are doing the right thing we have good evidence from feasibility Recruitment and putting it embedding it in the hospital setting and how it would sit with other systems so you don’t uh create more work uh but make life easier and um we have a lot of interest in fantastic clinical Partners uh fantastic clinical support what we don’t have quite yet is the caveat around the escalation pathway and what where how but we have done the ground workor around that and that will be a consensus process over time what we also don’t have yet properly is a good training package around this kind of and that would relate to physiology ctg in some ways as well as you’re you know that asking that question fit labor what does it mean and how how do we use it best so it’s one thing usability around buttons do I understand what the two is telling me how do I quickly when I’m tired use it uh but also uh you know what does that mean to me clinically how do I embed it in the context of what I see so we we’ll be doing that but the most important thing that we need to do is actually secure regulatory approval and that’s the biggest hurdle and that’s what I’ve been kind of struggling for quite a few years with for this to become an actual device that you can bring to multiple hospitals that it’s not a research device uh so if we like it if you want it if you if it’s useful and you want to buy it or or embed it so it’s not about buying it or having the money but it’s about embedding it so it’s going to cost very little because it’s software it doesn’t need to cost a lot unless you want to make it cost a lot and we don’t uh but um it still needs to have a big regulatory package on the back that impr that ensures that all the processes that it’s safe and it’s doing and that’s very costly and that cannot be done in a university or a hospital setting easily so we’re actually in the process of setting up a social Venture type of company uh that uh will secure that Regulatory and uh I’ll be very keen to hear what you guys here that’s obviously my vision here is a person who is putting in it it’s a spin out from Oxford it’s in the process of being set up but the way I see it as a NHS first because this is all NHS data and should uh serve NHS first and improving outcomes here um yeah and uh I’m working on this kind of Mission Vision and our current goal would be to actually get the Regulatory and be able to roll it out as a standard of care in uh at least five trusts in the next few years so shut up and thank you very much for your attention so much Antonia and te us I don’t hear you well Katherine I don’t know if it’s me is it just me no I can’t I don’t know what’s happened to her s she’s gonna have to mess her hair up and put her headphones on I think oh no oh no thank you very much Antonio and team absolutely amazing uh brilliant the way how far it’s come even in the last year of just talking about this to where it’s got to now is is absolutely amazing um so well done to you and your team and we look forward to hearing more about it in the future and look to those units that are triing it out I think um be great to hear back from those as well as to see how they’re getting on now it’s it’s getting outside of Oxford and into the units so uh so well done there for for getting that out there’s some questions uh in the chat I’ll let you um Anton I’ll let you answer them uh while we move on to uh the next speaker uh sorry a bit late I’d like to introduce uh CLA Wen from Brown Jacobson uh they’re they’re going to talk to us um today um around uh oh I’ve lost me little thing bear with me a second vetal monitoring um a claims perspective bran Jacobson recently joined us on a safety conference um at Uhl um and hopefully gain some insight into the world of fetal monitoring that they are uh looking at within this presentation so thank you uh CLA thank you very much indeed um for inviting us Sarah again back to monitoring may I hope everybody can hear me okay I don’t have conduct of the slides um so apologies uh my colleague Jenny Dodson is actually going to uh present the substance of this talk um so she has her hands on the the buzzer or the finger on the pulse or whatever you want to call it um but she’s going to be moving on the slides for the the first few few slides and I’ll do the introductions um as Sarah says I am a legal director here at Brown Jacobson um my colleague Jenny Dodson is an associate here as well we’re both part of the obstetric division um we’ve also been assisted in putting this presentation together by Kylie Bland and and thanks go out to to her for putting together some of the the materials that you’ll see on on the slides um together we’re here to talk to you about um fetal monitoring and really what we see as lawyers um what what comes across our desk on a on a day-to-day basis um I’ll just give you a bit of an introduction if we move on to the the first slide this is just a hint of what’s to come and I’m we’re going to try and keep it um as short as sweet as as possible um I want to tell you a little bit about bran Jacobson um what we do what our obstetric team do um then to go on to discuss why we’re talking about fetal monitoring and what as I say what what types of fetal monitoring we see as significant parts of of obstetric claims we going to give you a few examples some common issues um we’ve got a couple of case studies that we want to talk through um and then hopefully at the end there should be some time to ask and answer a few of your questions um what we also want to do just before we do finish and I think it’s probably quite important is to talk a little bit about what you should do if you’re contacted about a claim um because that obviously is the front of our minds when we’re dealing with it and and helping you as clinicians to to respond to request for information as of when you when you get them um I also want to start off with a bit of a health warning about this talk um we’re lawyers we’re not clinicians um I’ve just sat and listened to a very very complex and interesting talk um which I have to say a lot of that went over my head um but the point I’m trying to make is that when when we look at cases we’re looking at them from a legal perspective whilst we do have a good grasp of the issues and we’re always going to be guided by experts and clinicians in the field um and naturally as as part of our role we see things when things have gone wrong um that’s just as snapshot in time and I don’t think for one minute it’s an accurate representation of what goes on um dayto day on the delivery ward in the anator suite um as Sarah said we were at the um university hospital at leicester’s uh maternity study patient safety day and I was absolutely thrilled and really Blown Away by all the strides that have been made of recent weeks and months to improve patient safety and I I know what we see is a very different perspective from from what you see on the ward on a day-to-day basis um we think or we’d hope to think that as trust lawyers we are part of the learning that goes on around patient safety I was listening to one of your talks yesterday um about uh the the difference between physiological interpretation and the nice guidelines and one of the things that came through through that was was the fact that um you are very alive to the issues and learning from the mistakes as part and parel of what goes on within the the the hospital setting um just to move on to the the next slide if if you wouldn’t mind Jenny just to say a little bit about Brown Jacobson and our team um we are a a firm of lawyers who are instructed by NHS resolution to deal with CLA claims brought as against uh Hospital trusts we’re part of What’s called the how team the health advisory litigation team and we have separate divisions within this team reflecting various different aspects of practice um we’re set up in this way to enable us to have a in-depth specialist knowledge um of that practice area and that will help us to spot Trends and particular issues with certain hospitals and trusts within our team we do have a wealth of experience we we we deal with the highest and most complex value claims um we like to say we’re are the Forefront of society’s biggest issues and we are acutely aware of the issues of maternity care provision not least through our involvement in dealing with the claims related to and arising from the oen inquiry and the report um and we deal with all types of maternity related claims so that includes maternal injuries and death birth injuries neonatal injuries Etc we’re instructed usually to deal with a potential claim on receipt of a letter of claim from cers acting for the injured party um but we can be instructed before this um for example if we get a request for records um and once we’ve been instructed we’re going to investigate a claim by way of obtaining comments and from the Clans involved obtaining expert evidence and reviewing the records and and any investigations into the incident undertaken by the trust and that is a precursor to providing an advice to NHS resolution and the trust as to whether this is the claim that should be resolved and by that I mean making a a compensation payment or or whether it’s um capable of being defended or or not um I think that’s probably where my introduction finishes because from here on in Jenny’s going to take over um she’s going to explain why we’re talking about um monitoring in the context of clinical negligence and and go through the case studies so over to you Jenny thanks Claire it’s an absolute pleasure to be here today thank you so much for your time we’re really excited to talk about our work in the obstetric team and our kind of perspective on FAL monitoring so just to get straight into it why are we talking about the issue of fetal monitoring well it’s really an issue that crops up kind of time and time again um in the HC reports that we’re familiar with and the internal investigations done by trusts it’s also common feature in the claims that we deal with and we know that when fetal monitoring goes wrong this is commonly associated with poor outcomes and potentially claims we just have some statistics here from the most recent NHS resolution annual report and kind of the most significant point to note there is the second to last bullet points um maternity claims Remain the highest value area of NHS resolution spend so there was um a total 65% in maternity claims um for the for that year and this cost just under um 45 million in the financial year 2022 um to 23 so just a bit more about the claims and numbers and I appreciate that you can’t quite see well can’t see very well it’s very small writing there so I’ll try and be clear when I’m reading this out so we can see from the first chart just at the top there that obstetric cases made up in number 133% of all clinical claims in the financial year 2022 23 and the second chart just below that one shows that in terms um purely of value obstetric cases made up are whopping 64% of all clinical claims in 2022 23 so this is just to really show that maternity issues um are highly relevant to NHS resolutions budget in terms of dealing with clinical claims overall um and pass of our work is to make patients safety recommendations um and we encourage and make recommendations um for lesson learning from our cases just really trying to do what we can to to BR bring down the number um of these claims um and the overall cost um to NHS resolution so we’re talking here about the real cost of claims so um obviously birth injury cases are some of the most devastating in terms terms of the human impact um a lot of the cases we deal with involve um profoundly disabled children um and obviously birth injury changes the shape of that child’s life and also um the family we also deal with um cases involving neonatal deaths and still births which also have um a profound effect on families um the other side of that is that there’s also a big um kind of consequence for trusts um not just in terms of kind of reputational damage but we see how staff can be um kind of affected in terms of their own uh emotional and kind of mental health response um it can be a very uh distressing um situation to be involved in these cases and we know that um staff take it kind of uh very badly if there’s been a a bad outcome for a child and so really it’s just to point out that these we need to do whatever we can to reduce um the number of these cases and that’s why it’s so important to talk about um maternity safety and in this situation fetal monitoring so um which types of fetal monitoring feature most commonly in the claims we see against the NHS so we’re mainly talking about um ctg monitoring here but also we deal with um other issues so uh we’re familiar with uh fetal heart rate being monitored against contractions um the need for use of uh kind of H handheld doppler um and obviously uh fetal blood sampling is very helpful um in labor to assess the baby’s condition and to um measure fetal acidosis um we we say this that this is kind of our understanding of these um types of fetal monitoring but as CLA said we are lawyers and um we’re not um we’re not medically trained um but we are the only um panel firm for NHS resolution that has a specialist obstetric team so in that way we have got a very good uh knowledge base um in obstetric issues as far as as far as lawyers go um so we can just move on to um the next slide so this is how we would see a ctg um in a patient records and one of the first things we’re doing in in a handling a case is to get the patient records and then to identify and sort them out to identify the key records so we’re looking for a really clear legible copy of the ctg trade um this is just an example of a normal Trace as we’d see it in the records um sometimes we find kind of uh clinician annotation on a trace which can be really helpful because we’re really looking at these um traces kind of minute by minute um and it’s really helpful to just see from notes how it’s been interpreted at the time so what’s the use purpose um and limitations of ctg um so obviously it’s to um it’s for fetal heart rate monitoring and monitoring of contractions the purpose being to identify fetal hypoxia and if the baby’s not coping to escalate to delivery we know that ctg um monitoring does have its limitations um being a screening test and not being diagnostic but um there’s no be better method as we understand it to assess um the fetus in the womb and that there are um problems in interpretation um of the ctg Trace so we know it’s not a perfect um it’s not a perfect way to to monitor the fetus in the womb so why is uh fetal heart rate monitoring so significant in birth injury cases so this is the kind of issue we see most commonly the usual claim um made by a claimant is that the baby would have avoided a period of damaging hypoxia if delivered earlier and there would have B been born without cerebal policy or with a less severe form of brain damage so the common theme is you should have delivered the baby sooner um so obviously fetal monitoring is most significant here because it shows us when the baby’s in trouble so when we’re looking at these cases after the event um we ask our experts to look at ctg ctg traces very kind of forensically um we’re looking at at things like whether there’s been repeated decelerations on a TR trace or concerns raised regarding the trace uh we know that things like a single deceleration can be normal on a trace but um the clearest kind of cases where we’d see um immediate kind of red flag cases are ones where there’s been um repeated uh classified um classifications as suspicious or whether there’s or where there’s non-reassuring features or concerns regarding the trace that haven’t been escalated um this is even more so in high-risk labors um so ones where the mother may may have reduced um have reduced fetal movements previously or when the baby’s been identified as small for gestational age and we’ve just put there the every minute counts so um like I said our experts are asked to look at these traces um in great detail um we know that um well from our knowledge we we we understand that um the baby in the womb can withstand about 10 minutes of um hypoxia before this starts to become damaging and by the time we get to about 25 minutes we’re looking at a very severe disability and sometimes death and that’s why um it’s so important for us to look very carefully at fetal monitoring fetal monitoring throughout the labor we have some cases where babies would have been born um with significantly less brain damage if if born even kind of five minutes earlier and that’s why we’re looking at each stage of the labor and how um the fetal monitoring was kind of done at each stage um very very very very carefully so we just have a couple of case studies here these are uh real cases we’ve obviously taken out the sensitive data so the cases can’t be um can’t be identified so in the first case we’re looking at this was one where ctg abnormalities warranted earlier obstetric review and delivery so this was a baby born by C-section um the baby sadly suffered hypoxic esic damage and went on to develop respiratory and behavioral problems um the facts of the case were that the mother was admitted to Hospital for an adduction at 7:30 for an artificial rupture of membranes and at quarter past 10 there were decelerations noted on the trace by 11:25 there was reduced variability on the trace and she was moved to the left lateral position by 11:46 there were further prolonged accelerations and she was moved to the right lateral position by 12:05 the fetal heart rate dropped and by a quarter past 12 there was there was a request for obstetric review so a vaginal examination showed she was 45 cm dilated at that point and the fetal heart rate dropped again to 80 beats per minute at 21 minutes past 12 and the fetal heart rate recovered at 1223 there was a further obstetric review but no decision for a section until a prolonged acceleration at 12:40 and eventually delivery B section at um 5 minutes past one so our um independent expert um obstetrician and midwife in this case both agreed that earlier obstet review was required and a decision to deliver should have been made by about 1206 and delivery by 1236 and they explained the reason for this was that there were repeated prolonged accelerations on the trace that weren’t acted upon in that case it was decided that um in terms of medical causation if the baby had been born by 1236 this would have avoided the passage and aspiration of moonium avoiding respiratory support and the subsequent brain damage so this is really just a snapshot of of a case and it’s almost always the case that they’re kind of mitigating factors as to why um the concerns weren’t escalated and why there wasn’t um an early review and delivery um quite often we see this problems with there’ll be very familiar to to you there’s problems with capacity on the labor W um and the fact that the clinicians are simply so busy that um there’s an inability to um prioritize um certain cases or to escalate concerns in terms of um how we take those cases forward it’s it’s kind of unfortunate that um courts don’t tend to like capacity arguments um and it’s only a very rare case that we defend on the basis that there was no capacity to act um um the courts kind of tend to take a view that if something needs doing urgently um clinician should be able to prioritize and each trust should have processes and protocols in place to enable clinicians to take the Urgent action when it’s required so just to give another um one more case study here this involved um different methods of interpretation of a ctg trace um so this baby was born by um C-section following a FAL bradicardia with no recovery to the Baseline the baby was born with tetrolic distic cerebal py and the claimant argued that um there were earlier ctg abnormalities in the labor combined with um maternal infection should have prompted earlyer delivery so our consultant obstetrician in this case disagreed with the claimant’s um allegations and said that actually the ctg was normal throughout the labor apart from the odd deceleration um his view is that maternal temperature um was dealt with appropriately um blood cultures taken and antibiotics which was um reasonable action and there was no indication for earlier delivery this was quite um a kind of confusing case to us in the beginning in terms of the um the expert views um on the trace were so starkly different our experts saying something completely different to the claimants that we were actually questioning whether it was in fact the same trace and we took steps to check it there was no kind of mix up with the trace and it was the same ctg Trace that was being looked at um it then kind of became apparent that the experts were disagreeing because they were using different meth methods of interpretation it’s important to say that this was a 2017 case so at that time uh nice guidance was in place at this trust and our experts said that that was reasonable to kind of use the nice guidance to interpret the claim and expert is using um the physic theological approach so in terms of of the law we use the bolum test and we’d argue that um it was reasonable to use nice guidance because um there can be no breach of Duty of a responsible body of Obstetricians um at that time we’re using nice guidance to interpret the trace so that’s kind of a really interesting case in terms of um how this kind of will be dealt with in the future and we we think it’s likely that there will be more cases is where there’ll be an issue in terms of um whether clinicians are using nice guidance and whether they’re using the physiological interpretation and it’s likely for kind of more recent years as the uh physiological interpretation has kind of come to the Forefront um in the literature that a court will have an expectation that um clinicians interpreting a trace should just have um have their mind to the physiological approach even if nice guidance is in place and it’ll be interesting to kind of see what issues come out of that and whether any more claims um kind of emerge dealing with dealing with that issue so here we have just some other common issues and themes um that crop up in our cases kind of time and time again so misinterpretation or categorization of the ctg failures and escalating to delivery um incomplete documentation or a partial description of the trace with no classific ation um and we know that uh we can use the um ctg stickers to kind of help ensure all information is captured um failure to monitor by abdom abdominal palpation or assess contractions and that the labor has progressed inappropriate gaps in monitoring and documented plans for review not being actioned monitoring that indicates the baby’s in distress but this not being communicated to parents and failures and consent and just to say a little bit about that because the um consent is a really hot topic in our cases um and in fact we have we deliver presentations solely about consent and the law surrounding consent um but in terms of fatal monitoring kind of the most important Point um is to say that there’s been recent case law suggesting that um a court will expect um if there’s been any medical uh change in the um any change in the medical landscape if there’s been um significant change in pattern of the ctg it would be expected that there should be a fresh consent discussion with the mother at that time um and a kind of a fresh uh discussion with her about the options and her option of elective section even if that’s something that the clinician wouldn’t actively recommend um at that time so the last point there is just not performing or documenting maternal observations alongside fetal monitoring to assess the whole picture so really that’s just saying that um we a court would expect a clinician to have a kind of holistic approach and to lost you just on mute sorry I’m still here can you hear me yeah good okay so the last point there was just um failing to perform Eternal observations alongside fetal monitoring so this is really um the issue in these cases are perhaps when um the care hasn’t been looked at holistically um and where things like previous risk F risk factors or history of things like reduced fetal movement or uh a baby being small for G gestational age aren’t taken into account um when dealing with the actual labor itself so if I can just move on to the next slide um so what happens if you’re contacted about a claim so the typical processes and it’s not usually as um kind of formal as you might think um you might receive an email or a call from the trust um just to notify you that we’re looking at a case and we’re looking to speak to the relevant staff and then we usually send you the medical notes by a secure data room and ask you to have a look at the medical notes and prepare some written comments or have a chat with us um and then we just kind of take uh your evidence in terms of what care you provided at the time it’s quite often that um the case that clinici just don’t remember um specific cases and I think that’s very normal when you’re dealing with patients day in day out um so what we would normally ask then is um what would your usual practice have been um and that kind of combined with the medical records will give us a picture of what actually what actually happened um and that’s why really it’s it’s so important to make um a thorough notes of your kind of interactions with the client and everything is really well documented because that’s really what lawyers kind of rely on to defend cases or to work out just what what’s happened factually so if it’s the case where we’re making admissions um it’s nearly always the case that we don’t need too much involvement um from the staff after kind of an initial interview but if we’re um in kind of a liability dispute and we’re denying some of the allegations we may ask for a written um statement but it’s nearly always the case that um these cases aren’t taken to trial it’s a rare case that does goes to trial so it’s normally just a kind of paper exercise that we prepare a statement and um after we’ve interviewed a clinician it’s normally the case that we don’t need for them to be involved again sometimes we do ask clinicians to attend our conferences just to help us with the kind of factual picture but um in most cases it will be an initial interview and then nothing um so subsequently so there has been um helpfully a real shift away from um litigation and towards resolution as obviously evidenced by um NHS resolutions named it used to be um the NHS litigation Authority and um really now all cases we try and work as collaboratively as we can with um with the other side um to get the cases resolved and really to be just open to what the families um are seeking to achieve from um from these claims so that’s kind of the last slide we have before questions but we just kind of um first of all wanted to direct you to our maternity Services resource Hub on our website that has some really useful information um free training materials and resources to support maternity staff um with claims and inquests so we’ll be more than happy to um sign post due to that if that would be useful for you um and finally just to really say that while the material is is by its nature quite negative um we know that our Hospital trust clients work tirelessly to make maternity safety improvements and we’ve seen so much really excellent work being done um and on a personal note we we really enjoy working with clinicians it’s kind of one of the best parts of our jobs is to have those discuss discussions with clinicians um and we meet some really really lovely kind of forward thinking people so um thank you so much for for having us here and um yeah we’ll take any questions um if if there’s questions thank you you’re working now Katherine thank you so much both of you uh it’s so nice to to have you here and actually Katherine’s just messaged me and said we could have done with you for a couple of hours really to uh to get everything out are you there now Catherine I am can you hear me you can yeah I was just I just wanted to um ask if there’s anybody who we’ve not heard from already who has got any questions that they want to ask because I’m aware that there’s 150 people in the room as it were so I just wanted to invite anybody who may maybe more junior staff in particular because there’s a lot of us on the call that are not giving face to face care right now um and those who are are rather senior who are in the room so I just wondered if there’s anybody who could share maybe any Reflections on when there is an adverse outcome and Reflections on documentation and the challenges because I think for me what I’m hearing is we’ve heard a lot when when Jenny O’Donnell presented yesterday and about the you know the failure to escalate or the failure to interpret and actually that sits amongst so a much bigger picture of the the why and I get that legally we can’t bring in the well we were under staff that day that doesn’t matter to that family does it and I think there’s there’s just a a big mix between what’s going on in kind of Peace Surf and you know looking after staff in terms of understanding the why but for that family it’s really hard to bring that aspect in and I think it’s those aspects of you know what you document how you document and everything so I just wanted to open it up to see if there’s anybody from who’s working you know clinically as maybe a more Junior Midwife or even any I know we’ve had some students on today so I just wondered if anybody would like to offer their Reflections who’s more Junior given that I’ve just talked for about five minutes about it I’m going to give an uncomfortable silence I won’t pick on you mixa I was going to offer and say what you’ve just said Katherine and say I’m happy to just go in the background and not I don’t mean to be the first one to hand off um anyway um you mentioned uh Jenny that thank you for like everyone said it was really interesting um and I’ll need to watch it again because I need to take it in better as well but um the issue of going forward and sort of physiological being um uh physiological being sort of the the standard that things will be judged on where where is that exactly coming from because um uh you know there’s so many variations and permutations of where people are using the guidelines nice Vego combinations of things um from a legal perspective where does that come from yeah so the law really says that you should have um a mind to any guidance or literature that’s um there at the time that’s in kind of common knowledge and if it’s the case that the physiological interpretation is more has become there’s been a shift to that interpretation and that information is out there for clinicians to know about um then we would usually see claimants kind of pushing along the lines of the information was there so you you needed to have a mind to it but the the difficult answer to give is that we haven’t seen this tested yet in a case that’s run to trial and it’s an emerging issue so we just really were kind of flagging that it’s it may become a difficulty in terms of we have cases from say 2017 when nice guidance was clearly in place and we can feel quite confident on those that the standard at that time was nice but we think it may become more problematic that as the years follow on from that time and as the physiological approach emerges more there will be a great argument to suggest that a clinician should have a mind to both even a trist is using nice guidance they the argument would be you should have your mind to kind of taking a cautious approach and if there’s something in the physiological approach in literature that suggests this should have been a cautious let’s get the baby out sooner or the trace doesn’t look as good then there’d be a greater argument to suggest that that I think it’s a really difficult one and um me and CLA were just kind of learning even more about this yesterday from um from one of your colleagues and I don’t know CLA if you you had a bit more to say about that or what your view is on on on that kind of quite difficult issue um just to say I think probably one of the the the starting points will always be what the trust guidelines the internal trust guidelines are and one of the pieces of the jigsaw as with any cases is first of all we will request and ask for sight of the guidance that was being that was in place and what was being taught to the staff at the time that this incident happened because you’re only judged as against the standard at that time of the incident and you know we’re all alive to the fact that you know medicine is is fast-paced in many aspects slower paced in others but um it’s only when the guidance changes um and you know that that becomes commonly applied that it will become part and parcel of what a reasonable body of medical opinion um would look to um so I think it’s it’s it’s it’s it’s it is emerging and that’s that’s why these cases going over over the next 3 four five years I fully expect to see more and more of these cases where different approaches are going to be adopted and the claimant solicitors will say we should have adopted this approach and we’ll say well these were the guidelines and this was the literature that we’re working from at that time um but as as Jenny says there there’s no settled position um for right here right now um but it it’s it’s what what you have all all doctors all all professionals who are judged by the bolm standard are expected to keep up to date with um medical literature medical advances and forms part and parcel of their knowledge Bank thank you um we have this ongoing debate um amongst my colleagues and quite similar and you can see from the chat that it’s it’s provoking quite a bit of discussion very similar to what we’ve had um recently anyway um as someone said in the morning guidance is a guide and clinicians make decisions you can’t fit one to all you know and Susie was saying that this morning as well um and then there’s a counterargument that by mixing up guidelines that becomes confusing um that one doesn’t fit everything no and you’re right and we heard yesterday about the fact that the the fact that one thing is being taught and another thing is is um you done in practice the guidelines where there are different differences that that actually creates a risk in and of itself so much so that I think the speaker yesterday was talking about it being on the risk register as something identifiable um as potentially giving rise to potential claims because of the difficulty in interpreting which guidelines or you which which way is is is right to go um one thing to also bear in mind though whilst we’re dealing with the bolum test and and what a reasonable body of medical practitioners would do um there is also a an expansion of that and without wanting to get into too much technical language there’s a another test the btho test um which even means that you you even if there is a a body of opinion you you can have a smaller body of opinion that dictates or suggests a particular course of action and that can still be reasonable and not negligent if that body of opinion is logical um so it’s it’s not uh it’s it’s not just based on what is reasonable it’s what is reasonable and logical and if that can then be supported by um a body of logical opinion and I’m sure that’s where this whole issue of the physiological as opposed to nice is going because there are eventually well there are more there is more than one set of views as to to which interpretation should Prevail um someone’s just ask in chat what I was going to ask what’s the name of that other test BL you b b e l I think it’s b o l i t h o if my memory my dyslexia doesn’t prevent me that’s around that in Google that’s it you I can’t see who’s there’s somebody else with a hand up is sorry I’m I’m Ober consultant in Darlington it’s uh thank you for such a lovely presentation my question here is um regarding the importance of including physiological um fetal monitoring and nice guidelines both in your teaching days how much importance will be given to this fact when a case goes wrong so when they looking okay yes your guidelines is this but you have been taught about it physiological so would that means you should still be actually performing to that standards because it is a part of your training I think that’s clear you know you’re you’re very and this is where as lawyers I’m going to fall back on the law is is really really gray and it’s uncertain at this moment and because we are in a state of flux um it’s really really difficult for us to say what what would win out in that argument um without cases being tried and and tested our expert Obstetricians are very alive to these issues and and um we’re finding as I say that it’s coming through in the cases that we see um but we haven’t got a resolution to that at this stage thank you sorry s you’ve got your hand up you drawing us to a close because we are running over and I appreciate I was going to draw you to a close but probably not in in the right way because this is something that I say I feel like I say every month that the difference between physiology and a physiological approach we’re asking people to teach fetal physiology we’re asking people to understand why the babies be in the way it’s it’s behaving physiology has been there since we’ve been at school we we understand our body’s physiology that’s what we’re asking to be taught we’re not asking for people to teach the physiological approach we’re asking people to understand the why the baby’s behaving the way it’s behaving and I say it all the time but and we talk about it and we talk about hypoxia hypoxia has been there forever we’ve always had acute hypoxia we’ve always had chronic hypoxia these situations have always been there um and we’ve always had them they’ve just got different names it the difference between a physiological approach I feel is is that evolving hypoxia that we would classify as suspicious if you’re nice or fego but it’s understanding the way the baby’s responding that’s what we should be teaching we should be teaching how to get the baby out of that situation that it’s got itself into for whatever we’ve done to it not whether what kind of classification it is and I think I think that’s the key and I say it all the time and I’m sorry for harping on about it but it feels like we’re getting so bogged down with classifications and things like that but what I would say is is that is that education in that in that thing does it teach physiology and how the baby’s responding if so then that’s what needs to be applied when you’re not responding in a way that you should be does that make sense but thank you so much I did say we we probably should have had it for longer next year guys yeah um face to face uh an hour session with you uh if that’s okay and I can see there’s loads of questions in the chat and what might well do is we’ll we’ll work our way through them as as best we can but thank you again for inviting us really really lovely to see so much thank you thanks so much are you going on me Katherine go on you go you no you go okay so sorry we’re running a little bit behind I do apologize but I’d like to introduce CLA stora and Emily Stringer who are joining from mnsi or the old H um to just to uh talk around um the themes around good practice around fetal monitoring that’s happening nationally in last few years um now again they spoke at to Uhl recently and it was a really uplifting positive uh presentation so I think we’re going to end the day with two positive presentations so over to you guys thank you um I’m not sure what you can actually see on the screen is it just the bit um the blue bit and the changes in themes so apologies for that first time I’ve shared in a while in teams so thank you for inviting us and probably a lot of what we’re going to go through this afternoon is feeds into the previous sessions you’ve already just done and being on about and a lot of what we’re finding is probably going to be having been discussed as well so like you say you asked us if we could bring something on uh learning around FAL monitoring from the reports and our investigations and we are only part of one team but we’ve tried to bring together from the national team from what we could find so um right let me that way so where we started and it’s not going to show me everything now is it I start stages just so um yeah it’s not for some reason it’s not showing the um let me see if that no it’s not working is it I knew something like this would Happ so on this road map there is a sign that says 2018 where we started so in 2018 the healthare and safety investigation branch of Maternity in and maternity investigation program was commenced in England and we were commissioned by the Department of Health and then in 201 by April 2019 we were live in all trust so just a little recap for everybody and then um in 2023 um hsib became mnsi and so where are we now so as of the 1 of October last year um like I said H it became um the maternity and newborn safety investigation program we are now hosted by CQC however we are still independent and we’ve retained that independency and there’s no no changes to our investigation processes and we continue to be commissioned by the Department of Health now we know we’ve put that in cuz we know when we initially transitioned across this was the big question and the big concern coming from truss that we would be sharing everything with the cqt that the cqt would be able to see all of our data and they can’t it still works as it did previously when we were hsib our case criteria um needs referred to us are any babies Bor following labor or having started in labor after 37 weeks where the outcome has been an inart still birth on that front if if a lady rings with reduced people movement and said she’s as any pain um we would count that um early the innatal death in the first six day first week of life um of any cause uh potentially severe brain injury diagnosed in the first days of life and also maternal deaths um so this is the most recent National picture up to the 31st of March 2024 there have been 5,576 referrals submitted 274 of those have been rejected for one reason or another they might not fit the criteria or we might not go get sent from families to undertake an investigation 3,52 of those have progressed to an investigation and up till the end of March this year 3,151 reports have been completed um to break it down a bit further we’ve done a table that you can take in and read yourselves but year on year what refills met the criteria what referrals didn’t how many progressed to investigation and like I’ve just um said the reasons that were rejected um at the mo from at the end of March there were 351 investigations ongoing um like s I’ve already um said about the others so I’m now going to hand over to Emily um who’s going to do the next few slides for us um yeah so we were asked to present from National [Music] St can’t hear you sorry I’m not no it’s just really low really like you’re in the background is that any defit yeah it’s a bit better try it um I’ll just ra um so we tried to do a like like comparison of posters a few years apart which um was challengeing because Co was in the middle of it and we slightly changed our criteria preo it was any baby with the Char um during Co it just um so the way we went about this when we ped um places with take recommendations around monitoring about 3500 different and that was an work so we look at the earli year from when started um and St FES which was a bit more manageable so we those places the most recentes that we’ve had and that b is curent as of February February um and we looked at very sa recommendations and then Emily um I’m really sorry to interrupt you have you got any headphones at all or or maybe because people have really struggling to hear you I don’t sometimes if you turn your camera off so I don’t don’t take offense please but sometimes it justes it does just make the sound a little bit better doesn’t it so just a thought not really it sounds like you’re under water which I’m sure you’re not but it um right I’ll speak closer better that’s better that’s better that’s better excellent right thank you so we um we break these safety recommendations down into further subes um so the green columns are the 2020 recommendations and the blue columns are the most recent ones so um it can group interpretation and escalation processes together it’s quite hard to separate those out from some of the recommendations um and then also so the first three C you can see that they’re broadly similar when you adding them together um but you did notice a huge increase in the safety recommendations which involved P quality ctg so these are percentage changes that we made interpretation esal stayed around the same um a really notable Improvement in intermittent tication safety recommendations um and you can tell that um training around Compu with’s regimen has been really effective and in practice because they have a 56% reduction in that area um but the huge increase touch on interpretation and escalation um the from communication and there shouldn’t be a on individual who um obviously individuals are accountable and should be that’s not but um there should also um so looking at the breakdown of the subes there was an under authorization of M escalation tools so by that we really name the stickers for hourly flash eyes when um you’re completing ATI and you’re identify do uring or suspicious then what you going to do about that so you found the tools that really broke down the next step the star um were really helpful um and it comes to be those places where we don’t have those um EtG all funny again sorry Emily shall I take over are you sure yeah I’m I’m presuming you can hear can you hear mine okay I can hear you yeah yeah so if I I think you’ve just about covered this slide anyway haven’t you Emily is that right I think the main thing um that wanted to get out was that you know there’s the fear of escalation we’ve come across in the past the cultural leadership the importance of multidisiplinary train training um which has been in quite a few reports and hopefully an open culture as well where challenges accepted from junior staff as well as you know more senior staff like you’ve been saying with our junior staff here today and the main thing to highight was it’s not a lack of situational awareness situation awareness is often characterized in National reports as something that is under an individual’s control as a result training is often proposed as a means of avoiding loss of situation awareness however situation awareness is more appropriately seen as the outcome of the interaction between staff and all the other elements that make up a work system and an is an organizational issue um that came from one of the um HSI be um inart intervention reports um leading on from that intermittent osculation um we’ve observed obviously improvements because of training packages implemented into trust so actually um between the two two lots there’s been a 38% reduction in um AA safety recommendations of the most recent um ones that were reviewed um there were 16 recommendations around 11 were around supporting staff um to undertake at a recommend you know the recommended frequency um escalation if they’ve got any concerns and training um leading on to computerized um mon ctg monitoring um and I know I’ve heard this mentioned earlier this afternoon um the evidence that training in this areas get is becoming embedded into practice there’s been a 56% reduction in computer ICT monitoring safety recommendations and um the most recent ones have been it’s about that ambiguous area um of when uine activity is present and is it lat phase is it labor is it is it before um and there was one around supporting staff to used computerized ctg in line with guidance which is probably the same sort of things again um the biggest increase we had like Emily said earlier was around poor quality ctg tracing themes um and in with that came lot of ctg difficult to monitor um loss of fsse contact or um staff that didn’t know how to use fses with the ctgs you know new new qualified staff um we’ve had trust where where new FSS were being implemented but they didn’t actually fit the ctg M machine that was to it was to be used on um sometimes it could be staff you know not wanting to ask for support to monitor but that could make a difference um big ones escalation again um and supporting staff to continue ctg monitoring when a mother’s having anep jural or a spinal um or if she’s get up to the toilet so it’s thinking about things you know is their um Telemetry are you know are the monitors in your trust old are they fit for per purpose because we these are some of the things we often get told we ask about a quit when we meet with staff is the you know the poor quality ctg because of external fact such as maternal abitus um twins things like that so we we understand that all these things can Factor as well um and we’ve also come across things where the Doppler battery was flat um as well um so improvements so like I explained earlier we’re what we’re one team of about 11 in the country and we’re Midlands um to East Central North so we cover most of the Midlands from Lincoln to Shrewsbury and uh these we have these are the improvements that we’ve seen as a team over the last five years so we know there’s been an increase in training packages in trust and staff coming to events like monitor in May um and we know that there’s increased ual you know training it did taper off a bit during covid but what we find in is trusts are bringing back face tace training now um we found that the updated fresh eyes stickers and Analysis stickers are supporting staff with better documentation and also it helps that thoughts process um like you’ve just mentioned previously the you know phys ological ctg interpretation we’re finding that’s coming in more and more and consistency of the analysis by practitioners of using that when they’re reviewing fetal well-being and within training and also we found you know sharing of best practice um like the uh hsib newsletter so the one that on screen is one that um Lester shared with us um was in a news letter that what they had done around um improvements following a recommendation from a report and what they’d implemented into practice and things um so we know that there is improvements out there and we are seeing it um and I think like any Midwifery maternity you know the day we think we’ve got everything something else com about is on the book weren’t it because it’s it’s an evolving um practice um I seem to whisper this sorry um but what we wanted was we thought you know some pause for thought and questions on the back of you know we’ve just done a quick snapshot between like two 2020 and 2324 and you know just under 400 um reports but does what we’re say does it sound familiar um have you found the changes the same as we have does it reflect what’s actually happening in truss you know with examples and any questions thank you both um do you know what I I sat here reflecting on that not just because of the last slide that you showed which did get to me and I’m holding it together right now but um the changes that have been made is amazing and the difference of those recommendations that are coming through is I think it’s really important for everybody to share and everybody to see that especially um as fetal monitoring leads I I I don’t know whether you’ve attended any of the other sessions but it was very much if when there’s a poor outcome that’s to do with fetal monitoring it’s taken very personally um by the fetal monitoring leads and the people all involved in that education around things so to see that that snapshot even if it is just a snapshot of the the changes um and the reduction in in the recommendations around fetal monitor nationally um for me as an ex fetal monitoring lead um is is quite heartwarming really it’s because it shows that the hard work that everyone’s doing to make the differences they’re listening to the reports they’re um they’re making the recommendations and the fact that we share that change you know if it’s gone wrong in another unit share it with the other units that have made a difference and and that’s for me I think that’s what we asked last year of um H and mnsi that that link up was brought together um and it’s really important that that those learning from other trust is shared when they’ve made really good improvements as a result of a of of a um a report somebody else is probably in that same situation so you know that’s the whole reason that monitoring May and the feet and monitoring network was set up was to share don’t reinvent the wheel you know let’s let’s share that so that somebody else isn’t in the same situation and that those reports that you’re writing um get less and less with those recommendations if that makes sense it does make sense and hopefully going forward that’s actually one of the things that mnsi is planning on doing we obviously it’s having to get permission from trust and things I knew that I’d got permission to share that last because it had already been done and obviously I’m lead with Lester so I knew I’d got that but hopefully going forwards that is one of the thing like things that we want want to be doing sharing that good practice because there is a lot of good practice out there and we do come across it in trust but we can’t always share that because obviously we’re doing confidential independent investigations but this you know we should be able to share it and you know by getting consent to do that we can do it within our trust but also moving forwards that’s what we should be doing I totally agree has anyone got any questions at all or Reflections on that Katherine have you got anything you wanted to add I think it’s just um reflecting on the spot I would say that um when you get positive feedback like where you were clearly to have I Frozen or is it Sarah no she’s not um I think when when you get positive feedback and you talk about the influence of the Fatal monitoring Midwife and being influential in reestablishing twice weekly ctg meetings that are well attended as well as initiating intelligent intermittent oscilation assessments as part of mandatory training she has also been influential along with the team in the development of a month of shared learning across the network throughout May 2021 and we all know who that’s about and I think given the the pressures that people are under that to get that positive feedback and this is not holey 24 this is evidence-based that to get that positive feedback to allow you to feel valued is immeasurable and knowing that the pressure people have been under since this report was written to be reminded of it is really great as well Claire so I would thank you for that and I think it’s really beneficial to just pause and say to each other thank you and you are doing a good job it’s just it’s so easy to say isn’t it it’s hard to say it with meaning um for some people and given a busy shift it can be really hard at the end of The Busy shift to just stop and say thank you to people but I think that feeling of being valued we’ve talked about a lot around and about in the last two days and I think feeling valued in a a publication such as an M mnsi publication is is one thing but even the validation of just someone coming to your office door to say can you come and have a look at this ctg with me can can you can I just ask for your opinion or actually your opinion being given and being heard and respected is invaluable um so I think there’s a lot of place for learning from positivity and I think we have a duty I know you can’t do it from an mnsi perspective but maybe we have a duty as a group of fetal monitoring leads actually to share quarterly s similar to mnsi and share quarterly actually this is what we are doing that is really posit postive because if we don’t shout about what we’re doing well then it’s not very good just to expect somebody else to do it for us so I think we have got a responsibility actually to share nationally the good things we are doing because we’ve heard that you reports are getting less we’ve heard that there was 120 million less paid out in claims um in in a year and I think that’s phenomenal you know and it’s it’s not great that it’s not zero but it won’t ever be zero because we’re humans and but I just I do think we’ve got a duty now to share what we’re doing well and there might not be the appetite for it but so what I think we need to do it anyway that you asked Sarah I turn my camera off it’s all good I didn’t do it [Laughter] yesterday um yeah definitely um and we should share it and maybe maybe we need to come alongside mnsi instead I know that you’re an independent in you know independent investigation but actually maybe we all need to start to join up a little bit more and create that safer space and that safer environment in order to share that good practice maternity is massively under the spotlight and though and this this unfortunately this is what I’d love to shout about the fact that we have made a difference to those to however many babies in that report um that’s that’s the main thing and that’s what we need to share how many babies we’ve made a difference too because you know I had a text last night from a colleague who’s in Gloucester you know like thinking oh we’re back there again we’re back under the spotlight again you know Nottingham were brave enough to share their Journey this morning you know like we’re not down we’re not out we’re providing really good care to a lot of women and I think that’s where maybe we need to get the Press on board a little bit to share the positive things that have actually happened out of the negative um moving forward so yeah maybe we should I think we can take that forward definitely I’ve had enough silence now it’s time to start shout him any other questions or comments for the mnsi uh Team there’s a few things in the chat um CLA and Emily I’m not sure whether H you could probably go back and have a a little look about that um it’s hard to read them as we’re going along but we are really over so I am conscious of the time but thank you much for joining us I know it was quite last minute for you uh pounced on you during that safety conference to say can you uh can you fill a slot for us so um you know have to take advantage of seeing people face to face every now again don’t you rather than by email um so I guess that’s it rounded it up for the day I’ve put the link to today’s feedback form in the chat uh if you want a certificate for each day you need to fill each day’s form in I have changed the form that now says please definitely look at how you’re answering whether you’re happy about speakers because you’ve all giving us 10 out of 10 and you want us back again and then saying you’re very dissatisfied with every speaker so I’m not quite sure I think you’re looking at it slightly wrong so uh let’s make sure sure we get it right this time um and I’ve put a big comment in there to say make sure that you’re um that you’re looking at okay I think we’re back at 9: tomorrow aren’t we Katherine it’s another really long day bring your Pat lunch with you I think is the answer tomorrow and maybe your portaloo because whoever put the agenda together forgot to put Comfort breaks in so it’s a little bit of full on day tomorrow and uh if you’re at sheeld I can do some cafet and yes so we start at 9:00 tomorrow with Alex heel um and as you say very full day but what I would ask for I think is if those of you who have with your clinical links um I think the session on Coro amnionitis um from half to till four will be really beneficial for all those working clinically because I know a lot some of it is you know for those of us who are who are working hello Jo somebody doesn’t know me um so a lot of it is relevant for those of us who are fetal monitoring leads but I think you let’s try and get as many clinicians as we can and I know it’s a Friday afternoon so I’ve got absolutely no hope but if we can I think it will be very um valuable so thank you so much to everybody for attending today um I don’t think we’ve often dropped under 150 so participants so thank you the appetite is very much still there it would seem so have a lovely evening everybody um and we’ll see you again tomorrow see you later he pressing stop I’m doing it now before I wipe my eyes and my mascaras down my face thanks mate cheers mate you all right every time