Following the tragic death of three babies in Scotland and having considered all the information presented at the recent inquiry a report by Sheriff Principal Aisha Anwar KC has made 11 recommendations for midwifery practice and maternity service delivery.
Among the recommendations are reviewing electronic information records to improve alerts for at-risk women, that all electronic records should have a handover stored in the record if the named midwife has changed during a pregnancy. The report has also recommended having a direct telephone line to each maternity unit in Scotland for ambulance crews dealing with maternal and neonatal emergencies.
The RCM says it wholeheartedly supports each of the recommendations, including a recommendation for the RCM itself to review its Electronic Record Keeping Guidance and Audit Tool to include more guidance for midwives in triage situations in which they do not have access to the electronic records of a woman in their care.
Commenting, the RCM’s Director for Scotland, Jaki Lambert, said:
“If we are to improve the safety of Scotland’s maternity services, we must urgently review the processes, practice and systems that failed these families. All Health Boards across Scotland delivering maternity services must learn lessons from these tragedies: we owe that to the families who have suffered unimaginable loss to ensure that these mistakes are not repeated. We also owe midwifery staff robust systems that enable them to deliver safe, high-quality care and sadly those are not always in place. The inquiry ruled that there was a “lack of an effective means” to highlight risks in one of the pregnancies: in 2025 this should not be the case. We know maternity services can deliver safer and more personalised care using digital technology, but that technology needs to be right and enable midwives to deliver safe care.”
The RCM says it will urgently commence work on reviewing its Electronic Record Keeping Guidance and Audit Tool for members to encompass more information on what midwives can do when they do not have access to electronic records or paper records when triaging women in their care. The updated guidance will include information for its members on what to do if a woman’s full record has not been seen, and if it has not, the RCM says this should be clearly added to any triage document.
Jaki added:
“We are also calling on the Scottish Government to review its commitment to Best Start for a Scottish Electronic Maternity Record. This would enable appropriate action to be undertaken to improve electronic records in a timely manner to support midwives all those working in maternity services to access essential, potentially lifesaving information. It would also enable the wider healthcare community to share information across services. This particularly crucial when vulnerable pregnant women present to maternity services with social complexities and require more complex care from a range of healthcare professionals.”
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