Ensuring safer care for every newborn
This year’s World Patient Safety Day, organised by the World Health Organisation, shines a spotlight on the critical importance of safety from the very beginning of life.
Health Innovation South West has been supporting innovation enabling safer care for babies, before, during, and after hospital.
Safer care before hospital
Babies born unexpectedly at home, in a car or in an ambulance, before arrival at hospital, are at risk of hypothermia.
We launched a project to look at the circumstances around these births, to understand which women were most at risk of giving birth before arriving at hospital and the type of advice on neonatal temperature management given to callers who ring 999 about a baby born before hospital.
The project, led by Laura Goodwin, Associate Professor in Emergency Care at the University of West of England, has yielded learning in neonatal temperature management for UK emergency care that is already being implemented in the South West and taught to paramedics across England.
Hear how paramedic Katie McNee has drawn upon the research to drive changes in paramedic practice at South Western Ambulance NHS Foundation Trust.
Safer care during hospital
In hospitals, managing deterioration in babies and children is a long-standing challenge for patient safety.
Martha’s Rule is a major new initiative to improve the management of deteriorating patients, including babies and children.
All staff, patients, families and carers can promptly raise concerns if they notice changes in a child’s condition, and escalate them through structured conversations and 24-hour access to an urgent review.
Our South West Patient Safety Collaborative has worked closely with four acute NHS trusts in the South West to test and implement Martha’s Rule as part of the National Patient Safety Improvement Programmes. Martha’s Rule has since become available in all acute hospitals across the country, NHS England announced last week.
Meanwhile, another patient safety tool is helping recognise newborn deterioration early. The National Early Warning Trigger and Track (NEWTT2) framework charts vital signs and sets out clear escalation pathways to empower staff at every level to raise concerns about newborns and make sure action is taken in the right timeframe.
Fergal O’ Malley, Clinical Associate in Perinatal Patient Safety at Health Innovation South West and Advanced Neonatal Nurse Practitioner, works as part of the team providing care for families at Royal Cornwall Hospitals NHS Trust. Fergal has witnessed firsthand the impact of this tool.
“In Cornwall, the introduction of NEWTT2 is helping to keep babies safer during the postnatal period. The tool provides a clear structure for capturing vital information, supporting staff to spot early signs of deterioration and act quickly to prevent infants from becoming unwell.”
The NEWTT2 tool has been recently updated to recognise the concern of parents and the vital role of families’ observations alongside the wider care team.
Says Fergal: “The result is safer care for babies, and less separation between newborns and their parents at a critical time.”
In babies born prematurely before 34 weeks, a bundle of 11 evidence-based interventions known as PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth), can reduce brain injury and mortality rates.
The PERIPrem bundle was launched by Health Innovation South West and Health Innovation West of England in 2020 in partnership with the South West Neonatal Network.
There’s been national interest and spread since its successful implementation and evaluation in South West England, where maternity units have achieved the lowest mortality rate for babies born at less than 32 weeks’ gestation (NNAP, October 2024).
“PERIPrem, as a QI project, has had the greatest impact I’ve seen in 10 years at Torbay and South Devon.”
Dr Richard Tozer, Consultant Paediatrician, Torbay and South Devon NHS Foundation Trust
Safer care after hospital
For newborn babies showing early signs of an infection, an innovative new project is enabling their parents to take them home sooner.
NOAH (Neonatal Oral Antibiotics at Home) enables eligible newborns with suspected early onset infection to switch from IV antibiotics in hospital to oral antibiotics at home after 36 hours of treatment.
The innovative approach is moving newborn care from hospital to home – a shift particularly important in a rural region like South West England, where families face long travel distances to hospitals and other neonatal care services.
Emily, Harry, and their young daughter Luna, from rural Woodbury, Devon, are one of the families to benefit. Emily was shown how to administer antibiotics to Luna at home.
“To be able to come home with antibiotics for Luna during my first few days as a mum made all the difference for us as a family”, says Emily. “It meant we could be together, and I’m so grateful for that precious time as a family.”
NOAH was awarded Best Local Project at the 2025 British Association of Perinatal Medicine Gopi Menon Awards last week.
Supporting safer maternity care for every newborn and every child
The Health Innovation Network is commissioned by NHS England to host the 15 Patient Safety Collaboratives, via the local health innovation networks – including Health Innovation South West. Our role is to support NHS organisations to adopt safety interventions and strategies, aligned with the National Patient Safety Plan.
By hosting the 15 Patient Safety Collaboratives, the Health Innovation Network is working with all 134 maternity and neonatal providers in England to reduce the rates of maternal and neonatal deaths, stillbirths and brain injuries that occur during or soon after birth, via the Maternity and Neonatal Safety Improvement Programme (MatNeoSIP).
To date this programme of work has saved up to 1,692 lives, prevented 554 cases of cerebral palsy and supported almost 100 organisations to implement tools which improve the early recognition of deterioration of women and babies, leading to timely escalation.
And because of this work, 708 babies have avoided Strep B, 1,692 babies survived because of receiving the care bundles and 313 babies survived due to antenatal steroids and 1,202 babies survived due to optimal cord management.
