HSIB report calls for change to 'postcode lottery' 999 call advice for mothers awaiting ambulances for maternity emergencies

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Healthcare watchdog, HSIB, has published its latest national investigation report, Maternity pre-arrival instructions by 999 call handlers. The national investigation followed an HSIB maternity investigation into the telephone advice given by a non-clinical 999 call handler to a woman who was experiencing recognised symptoms of placental abruption, a life-threatening maternity emergency.  The findings of the individual investigation, combined with HSIB’s experience of 15 other incidents involving potentially harmful 999 call handler advice, led HSIB to launch the national investigation.

HSIB’s findings expose serious gaps and inconsistencies in the triage (prioritising) systems and advice given to people calling 999 with emergencies related to pregnancy and labour. The report aims to help improve patient safety in relation to the instructions that 999 call handlers give to women and pregnant people who are waiting for an ambulance owing to an emergency during their pregnancy. HSIB recommends that national guidance, regulation and improved patient safety incident investigations are needed to stop the current ‘postcode lottery’ in pre-hospital emergency maternity care. 

Incorrect 999 call advice given to mother waiting for ambulance for placental abruption  

The ‘reference event’ for HSIB’s investigation was the undoubtedly frightening and ultimately tragic experience suffered by a first-time mother and her family when she called 999 with signs of placental abruption towards the end of her pregnancy. She telephoned her local maternity unit for advice as she had abdominal pain and vaginal bleeding, and they told her to call 999 for an ambulance to take her to hospital urgently. She called 999 and told them about the pain and the bleeding and that she was alone at home.

Whilst waiting for the ambulance, the ambulance service’s triage clinical support system prompted the non-medical call handler to advise the mother to prepare for imminent delivery of the baby. This included gathering towels, blankets and sheets, and string or a shoelace (to clamp the umbilical cord after birth). She was then advised to lie flat on her back in the centre of her bed or on the floor and raise her head with pillows until the ambulance arrived. The ambulance arrived and took her to hospital where the baby was delivered by caesarean section. The mother was admitted to the high dependency unit having lost 1.4 litres of blood as a result of the placenta coming away from the uterus prematurely (placental abruption). The baby needed resuscitation and therapeutic cooling (to reduce the damage from his brain injury).

The potential for harm caused by the triage system and 999 call handler’s advice was only one aspect of HSIB’s investigation into this family’s care. However, HSIB’s concerns about the dangers of the 999 call handler’s advice, and experience of similar issues in the care of other maternity patients, led to a national investigation, illustrated by this mother’s experience, shared with the parents’ consent.

Key findings from HSIB’s report: ‘Maternity pre-arrival instructions by 999 call handlers

HSIB found that ambulance services in England use two different triage clinical decision support systems, including one that cannot be changed by the ambulance services here because it is controlled internationally and not based on UK guidelines. These are the systems which prompt 999 call handlers (who are not medically trained) to give advice to the woman or pregnant person (the mother) with the maternity emergency whilst they are waiting for the ambulance to arrive. In response to the symptoms that the mother described in this case, different triage support systems would have given different advice.

The system (and the non-clinical call handler) did not recognise the mother’s symptoms of constant abdominal pain and vaginal bleeding as placental abruption and the significance of this high risk complication was not recognised. The call handler asked the mother if she had any high risk complications and accepted the mother’s answer when she (also unaware) said no.  The triage system used in this case interpreted the mother’s reported pain to mean contractions, which differed from RCOG’s guidance that constant abdominal pain and vaginal bleeding are associated with placental abruption. The call handler was then directed to have the mother prepare for giving birth alone at home. This increased her risk of collapse as she climbed stairs and gathered things from around the house whilst experiencing blood loss from a placental abruption. 

The advice to lie on her back was also incorrect. Lying on her back whilst heavily pregnant with the weight of the baby on her   blood vessels in her abdomen increased the risk of further restricting the blood and oxygen supply to the baby. Alone at home, it was not possible for the unborn baby’s heart rate to be monitored, as it would be in hospital, and it would have been safer for her to lie on or tilted towards her left side, both for the mother’s wellbeing and to help the circulation of blood and oxygen to the baby.

HSIB found that the advice given by triage clinical decision support systems is not necessarily appropriate for a patient who is at home alone with no medically qualified person attending them.  It was acknowledged that there is a gap in maternity emergency guidance relating to the ‘non-visual, non-clinician-attended environment’. In addition to the lack of clear, relevant guidance, HSIB could find no evidence of formal regulation for 999 call handler pre-arrival instructions.

HSIB found that data hadn’t been collected about poor outcomes or patient safety incidents arising from 999 call handler pre-arrival instructions to women and pregnant people to lie on their backs, enabling the safety risk from conflicting advice to be understood. More generally, HSIB found that hospital or trust investigations into poor outcomes for mothers or babies only look at the hospital’s care. They do not routinely consider the impact of any instructions given by 999 call handlers to the patient whilst they are still at home waiting for an ambulance to arrive. Ambulance services were not informed by way of follow up after a mother or baby suffered harm after maternity care which included ambulance call handler care.

HSIB safety recommendations

HSIB formally recommended that:  

  • The Department of Health and Social Care (DHSC) should ask NICE to work with stakeholders, such as RCOG, to develop guidance for maternity emergencies in scenarios involving telephone advice for patients who are without any medically trained  attendant at home.
  • DHSC should identify a suitable regulatory mechanism to oversee 999 maternity pre-arrival instructions across NHS-funded care in England.
  • NHS England and NHS Improvement should develop the content of the patient safety incident investigation (PSII) standards for cross-boundary investigations (such as where the patient received both hospital and 999 call handler care).

Boyes Turner’s maternity and birth injury claims team welcome the important findings of HSIB’s national investigation into maternity pre-arrival instructions by 999 call handlers.  We support the call for guidance, regulation and consistency in 999 call handling and pre-hospital advice and care of women and pregnant people as they experience frightening and often life-changing maternity emergencies. We also support the call for better and more thorough standards of local investigation to provide parents and families with full, clear and open information about what went wrong. Where serious injury is caused to mother or baby as a result of negligent care, we remain committed to helping our clients claim their full entitlement to compensation.

If you or a member of your family have suffered severe injury as a result of negligent medical care, you can talk to one of our solicitors, free and confidentially, about making claim by contacting us here.


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