Review triage procedures used by NHS maternity wards

The Government should review how maternity wards triage patients, with a view to mandating a standard risk assessment based system for maternity and triage; assessing every patient within 15 minutes and prioritising care based on urgency, should be implemented.

Upon arrival at triage I was not seen for 40 minutes. I was not assessed for a further 1 hour and 5 minutes, then my CTG was not reviewed for an hour. I believe a lack of risk assessment and all of these delays were the reason for my son's death. If the hospital had used standard risk assessment based system my baby's death could have been prevented. Similar cases could be prevented if risk assessments are done properly and sooner.

We are very sorry to read of your experience and the tragic death of your son.

We recognise that, unlike mainstream emergency medicine, there is currently no nationally standardised triage system within maternity for women who attend for unscheduled appointments.

As a result, a lack of appropriate clinical prioritisation can have consequences for safety as women who need urgent care may be seen after those with minor concerns.

There have been local developments in relation to triage systems. Midwives and obstetricians from Birmingham Women’s and Children’s NHS Foundation Trust and researchers working on the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) maternity theme at the University of Birmingham, have co-produced The Birmingham symptom-specific obstetric triage system (BSOTS), which is well evaluated and has been implemented in 25 maternity units in the UK and a further 30 units have received training.

The system is based on established triage systems in emergency medicine and uses an assessment with clinical prioritisation of the common reasons that present within maternity triage. An initial standardised assessment of each woman identifies her presenting condition, key clinical symptoms and physiological indicators. Symptom-specific prioritisation algorithms use this information to define the level of clinical urgency using a four-category scale; green (non-urgent), yellow (requires further assessment), orange (priority) and red (emergency).

An initial evaluation of the implementation of this system suggests increases in the numbers of women seen within 15 minutes of arrival, reductions in the time spent waiting for assessment and the interval between attendance to medical review for those requiring it. Numbers of women who re-attended, and when they were next seen by maternity services suggested validity and improved safety. The system had excellent inter-rater reliability and midwives felt it improved safety for mothers and babies and the organisation of the department.

The Royal College of Obstetricians and Gynaecologists (RCOG) works to improve health care for women and sets standards for clinical practice, as well as the training curriculum for doctors practising in this specialty. NHS England and NHS Improvement (NHSEI) have been in discussions with the RCOG about the issue you raise, and on the work conducted in Birmingham, and will seek to take improvements forward once the appropriate clinical guidelines have been published.

In addition, NHSEI has written to all NHS Trust and Foundation Trust Chief Executives and Chairs setting out the immediate response required of all Trusts providing maternity services and next steps to be taken nationally following the publication of the ‘Ockenden Report - Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust on 10 December 2020.

The letter acknowledges that despite considerable progress having been made in improving maternity safety, there continues to be too much variation in experience and outcomes for women and their families. https://www.england.nhs.uk/wp-content/uploads/2021/01/Ockenden-Letter-CEO-Chairs-final-14.12.20-1.pdf

The letter instructed Trusts to confirm the steps they are taking to implement the full set of the ‘Immediate and Essential Actions’ set out in the Ockendon Report and 12 urgent clinical priorities from the IEAs by 21 December 2020. Individual responses from Trusts will form part of the presentation and discussion at the NHSEI Public Board in January 2021 when the report, and immediate and longer-term actions will be considered.

Department of Health and Social Care