The theme for this year’s World Patient Safety Day is Safer Care for Every Newborn and Child. In our latest Making Complaints Count episode, we explore what this means for families and the NHS.
Sandy Lewis, Director of the Maternity and Newborn Safety Investigations Programme (MNSI), joins Policy and Public Affairs Officer Roshana Amiri on the latest episode of Making Complaints Count to discuss:
- how families can be supported when something goes wrong in maternity and newborn care
- why listening to feedback is vital for safer care
- the biggest patient safety challenges facing the NHS in this area.
Listen below, or find us on iTunes, Spotify or your preferred podcast provider.
Roshana Amiri Hello and welcome to Making Complaints Count, the podcast from the Parliamentary and Health Service Ombudsman, where we explore the power of complaints and how organisations can use them to learn and improve. My name is Roshana Amiri, I'm part of the policy and public affairs team at PHSO and I'll be your host for this episode.
Today we're joined by Sandy Lewis, director of the Maternity and Newborn Safety Investigation Programme, or MNSI.
MNSI carry out independent investigations into patient incidents that happen in maternity care. They work closely with families, NHS trusts and staff to make recommendations to improve services at a local level and across the whole maternity healthcare system in England.
Sandy has overseen the roll-out of this programme across 125 NHS trusts in England.
Hi Sandy, welcome. Thank you so much for joining us today.
It'd be great to get to know you a little bit more. So I was wondering if you could tell us a little about your early life, your career and tell us what first drew you into patient safety work?
Sandy Lewis Thank you, Roshana. It's a pleasure to be here. Thank you for inviting me.
I am a nurse by background. I've worked within the NHS for too many years to mention. And my predominant area of expertise has always been around intensive care nursing. I worked in varying roles. I started my nursing career as a healthcare assistant and worked my way through to being a deputy director of nursing.
Throughout my career I've been hugely influenced by what I've seen in the areas I've worked and really developed a curiosity of what's going on in the world of patient safety. I've been privileged to work with many people who've influenced that over the years.
And so I think predominantly working within my latter roles in intensive care I covered areas such as operating theatres where you see some really critical events happen and I think that informed me to think about what patient safety looks like. And I then stepped into looking at safety investigations and governance. It's one of my roles I worked in predominantly in my career. It was around the south coast and then I've moved up to East Anglia and again I think I've been very privileged to work with a number of amazing clinicians and really influence those thoughts.
So I suppose that has taken me into a really defined role around patient safety. And I think giving me that privileged opportunity to really lead the agenda at a national level in relation to patient safety is that thought around ‘what does patient safety look like?’ And I think we see on a daily basis within that clinical role actually, how could that look differently? I think alongside the impact clinical teams have on changing the direction of travel in relation to certain events.
So I think it started around those areas I worked. I then moved across into the Health Services Safety Investigations Body (HSSIB) as part of that inception and had an opportunity to work with amazing people who have different industries, a different way of working and a different way of thinking.
It's certainly very fair to say I never step into a lift and look at a lift the same way anymore! You really think about actually, how do they structure lifts and different bits and pieces? And they made me think much more about systems and processes and taking it very much away from an individual and thinking if we change this system or process, actually what would that look like next time round?
I think I've been really influenced by that. And then again had that opportunity to move across to lead MNSI.
It has been an absolute privilege and I have been doing that for the last six or seven years, working with both an amazing team and a broad team in relation to doing that work. So it's been a varied career and I think the world of patient safety and how that influences safe care has quite long-reaching effects and has been quite profound for me really.
Roshana Amiri Yeah, absolutely. Thank you so much for sharing that. Definitely a very interesting career you've had and I'm sure that having worked on the frontline, you're able to bring a lot of insight into your current role. For those who may not be familiar with MNSI and what they do, could you tell us a bit more about how you work alongside families when something goes wrong in maternity care?
Sandy Lewis So I think firstly, it's really important to acknowledge that we work with families who are experiencing some of the most difficult and tragic events in their lives.
And working with them to share what's happened to them and to really think about actually, what does that mean for them? What are their key questions? What do they need to know?
We work across the whole of England. Each family get a lead investigator and a support investigator and they work closely with families throughout the investigation. Our role is to provide an independent safety investigation, so we are independent of the Trust and independent of families. And we're really thinking about what happened and why.
A key part of that is that initial discussions with the family for them to understand what are their key questions and what does it mean for them and what they want to know and understand. And they remain a really fundamental part of our investigation throughout.
We work very hard to think about what their individual needs are, what that might be in relation to communication, how do we support them, how regularly would they like to be contacted.
It's really important to think about the experiences that they are having. Some families are not ready to talk to us. Some of them are still trying to support and think about what that care looks like for their babies and for their wider family. Therefore we have to think about how we navigate working with them in a way that supports their needs at every stage along the way.
Apart from that, we work very closely as well with staff in the Trust. And a part of that independence is being proportionate in our viewpoints and really thinking about trying to balance what is it that we know and understanding why it’s happened.
We go back and we ask all those really key questions for the families and the Trust. We end up providing them with a safety investigation that gives them safety recommendations, safety prompts and that really informs care going forwards and actually makes meaningful change.
In relation to that, I think there's quite a lot of additional work MNSI do. We work quite collaboratively as well. When we talk about the work we do in those individual investigations, they really inform a much more thematic piece of work. Because we work across the whole of England, we're really able to draw on that information and actually think what's happening in one hospital, the likely chances that might be happening in another. We are just one piece of the jigsaw puzzle. The collaboration with other organisations is really, really important for us and we've really been able to expand and think about what that looks like.
We work really closely with the Chief Medical Officer and the National Clinical Director. We think about how our work can be informed and we work closely with people from organisations like NICE (National Institute for Health and Care Excellence), our CQC (Care Quality Commission) colleagues, because we are hosted by CQC, we've recently done some really interesting work with the British Association of Perinatal Medicine (BAPM) on a safety spotlight that's around blood transfusions.
We might know a piece of information but they can help us expand on that and really inform it.
We've been doing some recent work about resuscitative hysterotomies and again working with ambulance services, working at Warwick University, the team's been working with just to really think about that and see what that looks like.
So you know, a core component of our work is working with families in relation to our investigations, but actually what that does is inform a much wider picture around how we work on a national basis and really form this national picture. We're doing some work with the NHS Race and Health Observatory and there's a lot of work around inequality at the moment. I think everyone's increasingly aware of inequality in healthcare and answer the impact that is happening. So really thinking about that as well.
There's lots of great work going on out there alongside the work that's been really informed by our families.
who we have a privilege to work with.
Roshana Amiri Yeah, absolutely. Thank you so much for explaining that. It's really helpful to understand. And as you say, I think it's really key to listen to families and understand how to communicate with them and provide that personalised approach for each family. Because as you say, it can really differ for everyone. So it's great to learn more about that.
As you'll know, the theme of this year's World Patient Safety Day is ‘Safe care for every newborn and child’. From your perspective, what are the most critical safety challenges facing newborns in NHS care today?
Sandy Lewis I think what's really important is that we draw out what those challenges are. And we sit in a place where we've completed over 4,000 investigations. The themes that we are driving from are drawn from the data that we hold and really thinking about that thematic perspective.
I think there are several things around that recognition that a newborn is becoming unwell and really listening to mothers and families concerns. Those are really critical things that we're drawing out of our data. They're telling us actually these are some of those challenges that we're facing in that newborn world. We've done some work around perinatal collapses, but I think what's really important is us drawing on that recognition that listening to families, listening to mothers and thinking how does that inform that safety challenge that we have in the NHS today?
It is so far-reaching and the work we're doing with their families I think is starting to really inform that going forwards.
Roshana Amiri Great. Yeah. Thank you. Definitely something that we see as well in the complaints that we receive is that communication failings, families feel like they're not being listened to, the story's not being heard.
You'll probably be aware that in 2023 we published our own report spotlighting themes from maternity complaints raised by families. Why do you think that it is important for families to be able to feedback on the care that they receive?
Sandy Lewis Coming back to my original point, I think families remain fundamental and need to be listened to and they need to feel that they are being heard. I've been looking at your most recent report. A number of the examples that you share within it are very reflective of what we hear within our investigations, and whilst there's many complexities to making some changes within healthcare, the ability to listen to a family and acknowledge and respond to what they're worried about at that moment in time can change the direction of how they feel about the care they receive. I think coming back to what you've raised within your report, if you look at these obviously very key messages to be drawn out.
If a woman is in pain, she wants someone to acknowledge that she is in pain and to provide pain relief. That needs to be timely. That needs to be effective. The woman needs to be comfortable as part of that. That's maybe one example.
Women often are entering childbirth, and this might be their first experience of going through childbirth, and you don't know what to expect. So I think it's really important that actually, they're listened to.
I think another part is we hear from other family members that might be in the room. Fathers are often in the room and they feedback to us what they see and what they hear. That really informs our investigations. So that listening and being heard and being felt that the decisions that are being made with you in collaboration is really important for families.
Roshana Amiri Yeah, absolutely. Are there any specific stories that you'd like to share from your own investigations that highlights some of these issues that we've been discussing? And if you could maybe share a bit more about how you work with organisations involved to address the concerns of the families involved.
Sandy Lewis So without going into details around specific individual cases, I'm going to talk more in relation to themes. Firstly, I'd start with communication. The one thing we hear from families is communication is really key in relation to all aspects of care during pregnancy and after pregnancy. How they're listened to, how they're heard. And I think it really comes back to the previous question that I've mentioned.
Some of that communication, particularly for families, when things don't go as planned, becomes probably the most important. The families that we work with will often say to us that some of that communication is not as confident because people are nervous about what that means next. I think families just want answers, continuing that communication with families and sometimes that communication is difficult when things haven't gone as planned.
Families are experiencing some really difficult and tragic things in their lives. It's really difficult to maintain and understand what that communication looks like. But families tell us that's probably the most important point for them.
One case that changed the direction of travel, that a mother experienced in her further pregnancy, knowing that things hadn't gone well for the first pregnancy, was the ability to actually work with the Trust. To go in and talk to them and see where she was going to give birth and talk through her experience and then really feel that the staff understood what she experienced before. That made a significant difference.
We have to remember many families, because of the geographical layout in the country, may experience something in one Trust, but they don't have a choice. Their further experience will be in the same Trust. Ongoing experiences within healthcare for them and their family will be in that same hospital. And so I think it's really important that you know how they are cared for during that period of time and that really informs the subsequent events and experiences they have.
Roshana Amiri Yeah, absolutely. It's really that learning part, isn't it? How do you learn from a mistake and make sure it doesn't happen again? And it's very important for families to work together with the Trust collaboratively and with organisations like yourselves to achieve that.
So just looking ahead, do you have a vision for the future of newborn safety in the NHS or if there is one particular change that you would like to see prioritise, what would that be?
Sandy Lewis Oh, now there's a very big question, isn't it? So I think we need to keep in our minds that families need to be central to everything we do in relation to care.
If I go back to when I was doing frontline clinical nursing, and I also went back during COVID and did some clinical nursing, which I think probably reinforced my thoughts around this, is ensuring that our services and the care we provide is really designed and constructed around the care of what an individual needs.
Quite often we see within our investigations that a clinic is run on this day, and it's always run on this day. But actually a mother can't make it to that clinic, or the cost is prohibitive for her to get to that clinic.
So actually do we really think about how our services are designed for the needs of an individual rather than what fits and works or what we've always done.
Another area we always talk about in our investigations is families and mothers receiving complex care. So they were attending two or three different clinic appointments and they ended up going to the hospital on three or four occasions that week and that's really difficult for people to be able to undertake. When we're talking about families who are in deprived areas, the cost of getting a bus or all these other things become really prohibitive and make our services inaccessible to them.
I think we nearly really need to think about that slight change in how we fix the care around the individual rather than our services around our trusts.
There is a lot of work going on in relation to health equity and if we are able to provide and get our services and the care we provide to families as good as we can. Who are the most deprived and have many complexities, then moving forwards we're going to be able to achieve that on a much wider scale.
We really need to be focusing on our families and we need to think about focusing on individualised care.
Roshana Amiri Absolutely. I think you raise a really important message there about that individualised care. Thank you so much for that. And just finally, before you wrap up, if listeners could take away just one key message about newborn and child safety this patient safety day,
what would you want it to be?
Sandy Lewis So that's very difficult to put them into one message, isn't it? A part of me feels we need to ensure that the care we provide to our mothers and our babies at the start of life is as good as it can be. We need to make sure that we end up with families, mothers and babies actually improving their lifelong well-being.
And I suppose I know you're asking for one key message. Within the current climate of maternity and newborn care there's an opportunity to take a collaborative approach between families, between Trusts and all the people who are working within this area to all be striving in one direction. To ensure that the care is as safe as it possibly can be, it's individualised and that we don't end up with the risk that people are going to end up disadvantaged in relation to the care we're providing. So I think we really need to focus on those areas.
Roshana Amiri Great. Thank you very much, Sandy, for your time today. It's been really great to hear from you and just learn about the important work that that you do at MNSI. So thank you very much. I think that's all for this episode of Making Complaints Count.
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