In Advise, resolve and learn Our strategy to 2025, our second strategic priority is to share data and insights as a catalyst for improvement and our third is to collaborate to improve maternity outcomes. Aligned with these aims we have gathered together learning from our Early Notification Scheme and produced a number of case stories to help support learning from harm identified through claims.
Our case stories are illustrative and based on recurring themes from real life events. These experiences have been highlighted and shared with you, to help identify potential risks in your clinical area, promote learning and prevent fewer incidents like these occurring in the future.
We have also produced a case story guidance document which explains the various ways you can use the case stories, from individual self-directed learning to support continuous professional development to using them in a team environment. The idea is that by learning from the experience of others, maternity unit staff will be able to change their approach to care.
Our Early Notification case stories are available to read below:
- Navigating an Early Notification Scheme liability investigation
- Recognising and avoiding significant maternal and neonatal hyponatraemia
- Antenatal computerised CTG monitoring
- Good practice: management of shoulder dystocia
- Antenatal Cardiotocograph (CTG) Interpretation
- Delay in recognising placental abruption
- Delayed therapeutic hypothermia
- Good practice in managing umbilical cord prolapse
- Group B Streptococcus (GBS) in pregnancy and early onset infection in the neonate
- Home Birth
- Neonatal hypoglycaemia
- Undiagnosed breech presentation in advanced labour
- Use of intermittent auscultation for intrapartum fetal surveillance
- Management of hyper-stimulation and fetal bradycardia