Tools for frontline professionals

The way in which healthcare organisations respond and learn following patient safety incidents has been repeatedly highlighted as a cause for concern. Getting that right has never been as important as it is at the time of a national pandemic. Where things have had to adapt and change rapidly, new and unforeseen problems can arise.

In addition, ‘maternity scandals’ are increasingly being reported, where thousands of families have been impacted by substandard care, leading to tragic and life-changing outcomes (Buchanan, 2020; Ng, 2020). It comes as no surprise that a ‘focus on learning and best practice’ is listed as one of the five key drivers for delivering safer maternity care as part of the national maternity safety ambition and action plan (Department of Health, 2017). Learning from investigations and learning from best practice were cited as components leading to better care. In the Morecambe Bay Investigation, Dr Kirkup CBE reported ‘missed opportunities’, where future harm could have been prevented if good investigations, learning lessons, and positive action had taken place (Kirkup, 2015).