In a national report published today (Thursday 7 July) CQC has identified a lack of guidance and agreed best practice to support NHS trusts to identify and manage serious health risks in newborn babies and infants, and has made a number of recommendations to address inconsistencies in current practice.
These recommendations are being supported by the National Institute for Health and Care Excellence (NICE), the Royal College of Nursing (RCN), the Royal College of Paediatrics and Child Health (RCPCH), the Royal College of Midwives (RCM) and the British Association of Perinatal Medicine (BAPM), as well as a number of other organisations, all of whom have provided expertise and advice to CQC’s review.
The review looked specifically at the management of newborn babies and infants with complex health conditions in hospital and in the community. It focused on three areas of care; the detection of health problems during pregnancy through screening, the diagnosis and management of newborn babies with deteriorating medical conditions, (with a particular focus on high blood pressure), and the management of infants requiring respiratory support in the community.
Although the report highlights many of examples of good practice in each area, CQC found variation nationally, potentially due to the lack of national guidance about the management of at-risk babies and infants, and inconsistent processes to communicate information from one specialty team to another.
Commenting on the review, Professor Edward Baker, Deputy Chief Inspector of Hospitals at the Care Quality Commission, said:
“We found some excellent examples of good and outstanding practice and there is no doubt about the dedication and skills of staff that provide this very specialist care. However, we found a great deal of variation in the way that services manage clinical risks in babies before and immediately after birth, and in the management of infants that need support once discharged home.
“For all anomalies detected during pregnancy communication between specialist teams is essential. However, when major problems are identified, multidisciplinary meetings need to take place including obstetrics, fetal medicine and neonatal specialists. In some hospitals, this is routine, but in others it isn’t always happening.
“Parents need to be confident that newborn babies who need the most complex care will receive the same high standards wherever they live. Similarly, families of children who need long-term ventilation at home need to be confident that they can rely on professional, well-trained staff to care for their child after they leave hospital.
“We have identified a requirement for clinical guidance to ensure consistent high quality care across the country and we are grateful for the support of our partner organisations in taking this forward.”
Caroline Davey, Chief Executive of Bliss, the premature and sick baby charity said:
“This report highlights failures in the handover of care of babies with complex health needs between antenatal, obstetric and neonatal services – which mirrors parents’ own concerns about poor communication between professionals. In a survey conducted last year of parents whose baby was admitted to neonatal care, over one third of respondents said they did not feel the maternity team communicated effectively with the neonatal team*.
“We therefore welcome the CQC’s recommendations to tackle inconsistencies in the care of vulnerable babies with complex health conditions, particularly where their care is shared between different teams. Bliss strongly supports the development of new clinical guidelines. Urgent action is now needed to ensure a seamless service for these vulnerable babies.”
Ben Gummer, Health Minister, said:
“It is vital that these recommendations are considered as a matter of urgency. There are unacceptable variations in neonatal care and ensuring the very best and safest care for sick babies is essential.
“This Government is absolutely committed to improving maternity care – which is why we have set out our intention to halve the number of neonatal deaths by 2030 and have invested millions in training for staff and new safety equipment, as well as making sure hospitals review and learn from every tragic case.”
The findings in CQC’s report are based on evidence sourced during visits to 19 NHS acute hospital trusts, information from 16 clinical commissioning groups (CCGs) and eight long-term ventilation network leads working in the community. CQC also spoke with 10 parents or guardians of children with respiratory support needs living at home and receiving care in the community.
CQC found that overall, screening and referral processes were generally effective, with clear national guidance on screening for some conditions such as Down’s syndrome or congenital heart defects. However, processes were less clear to guide staff when other anomalies were detected or suspected.
Specific concerns were raised about the transfer of data from the mother’s notes to the baby’s notes at birth, given the potential for human error. Midwives spoken to as part of the review told inspectors that it also meant that problems detected after postnatal discharge were not always fed back to screening midwives and sonographers so they could review and learn from any missed anomalies.
As a result, one of the recommendations CQC has made is for a fetus to be assigned its own unique identification number, to which all its medical data and other relevant information can be linked. Doing so will improve accuracy of records, assist in learning for staff at the screening stage, and allow medical problems identified in later life to be related back to antenatal factors more easily.
When managing newborn babies whose condition could deteriorate, trusts varied in their use of early warning observation systems to detect babies whose health is getting worse. Some trusts did not use any early warning trigger tool at all.
All trusts measured blood pressure routinely when a baby was admitted to the neonatal unit, but the frequency of doing so is not mandated and depends on the baby’s condition, which could mean that problems associated with low or high blood pressure are missed.
CQC found inconsistency in which guidance different organisations used for the care of infants with a tracheostomy and those who need respiratory support once they had been discharged home. Factors such as the expected timescales for discharge, the frequency of multi-disciplinary team meetings and reviews of home care support packages, as well as mechanisms for families to receive feedback also varied.
Some of the families that CQC spoke with described positive experiences of their child’s discharge from hospital and subsequent support provided by staff in the community. However, others reported feeling a lack of confidence in agency care staff and concern that training for the staff providing care in their home had not been good enough.
The review has identified some very specific areas where additional guidance and clarity on practice is needed and has made a series of recommendations to help support improvements for babies, infants and their families.