In the guidance for Serious Untoward Incidents (SUI) from different hospital trusts that I’ve seen published on the web, a common example of the kind of adverse event that might start the process off is the death of a baby. Some trusts go as far as suggesting stillbirth - even as far back as the second trimester of pregnancy in one case I’ve seen - might also be considered. This reporting process theoretically leads to an in-depth, rigorous investigation into the events surrounding a baby’s death (including the good care, as well as the bad), and the process is probably already reasonably familiar to a hospital. The findings of these investigations are supposed to be reported to the hospital’s Governance Committee, and once the content is agreed, the Chief Executive releases some kind of a report for some kind of general dissemination. So, done properly, this process could be a invaluable source of learning in maternity and neonatal care. What makes it particularly important, is that these deaths represent the extremes of care, when problems and solutions are at their most obvious, and therefore also when learning should work best.
I think SANDS “Why 17?” could make some important progress by campaigning for the SUI reporting process to occur whenever a stillbirth or neonatal death occurs, and by informing parents and health professionals of the existence of this potentially important alternative to just coming up with something to put on the death certificate.
Unfortunately, the evidence suggests that generally, lesson dissemination is very poor, and our own experience of the process is that even the investigations are themselves done poorly. The reason this is the case is because no one, with the possible exception of the bereaved parents, is really paying any attention to SUI reporting.
The obvious way to make SUI investigations, and the reporting of them, more effective is to make SUIs either actually or potentially peer reviewed documents, more like medical research papers. This would force the staff involved to do a good enough job in their reporting of serious incidents to convince their peers of their findings, as well as help disseminate those findings. In our case, the staff involved in the investigation of the death of our son is yet to produce a report at all, and this means that we are still having to piece together what happened by asking questions. This is a pointlessly lengthy process, and makes understanding what happened and learning lessons from it almost impossible, even for other health professionals. I would imagine that if I was a medical doctor, peer reviewing their investigation reports, there would be a lot more effort going in to explaining things.
Lastly, unlike many other countries, the UK does not have a national network for NICU’s etc, where the dissemination of reports can easily occur. This situation means that even where something is learned locally, it has no way to spread except on the back of other slow processes like the medical literature. This sort of national collaboration is important for other reasons too (for instance, the recognition of GBS outbreaks), and is another extremely useful issue for SANDS “WHY 17?” to campaign on. By making a national network for SUI reports to disseminate within, peer review would also be encouraged.
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