NHS maternity signal system will spot and stop emerging safety concerns

Mothers and babies in England will receive safer care thanks to the roll out of a first-of-its-kind safety signal system across NHS maternity services.

The sophisticated new tool rapidly analyses data being routinely recorded by maternity teams on wards to spot whether there are potential emerging safety issues which need urgent attention and action.

If the system detects a pattern or trend in the data which seems out of the ordinary, it will send out a warning signal indicating a safety check should be urgently carried out on that unit.

NHS England's chief nursing officer says this new tool will help to identify and address serious safety issues and prevent tragedies.

Once a signal is generated, it is mandatory for the maternity unit to carry out a critical safety check within eight working days and share action taken with regional and national teams.

Signals will be traffic-light coded, with amber alerts representing a 95% confidence and red alerts, a 99% confidence that the increase in events is real and needs urgent attention.

The robust online system, named the Maternity Outcomes Signal System (MOSS) is now being rolled out across all maternity services in the country, seven days a week.

Retrospective analysis shows MOSS would have detected signals in maternity units that later experienced serious incidents, including East Kent, Shrewsbury & Telford, Leeds, and Nottingham.

The data and signals will be visible at a trust, Integrated Care Board (ICB), regional and national level – ensuring there is transparent oversight from ward to board and across every part of the system, to ensure concerns are acted on quickly.

National health chiefs have also told hospital executives to raise safety issues identified by MOSS at their public board meetings.

Duncan Burton, Chief Nursing Officer for England, said: “There have been too many times where safety issues in maternity could have been detected earlier, and we have seen the devastating impact this has had on families.

“Having a signalling system for maternity which can carefully look at data in near real-time and spot early warning signs if something is potentially going wrong will help to avert safety incidents and prevent tragedies.

“It is the first national system of its kind in maternity to be able to signal potential safety issues as they emerge and allow them to be acted on faster by maternity services.

“And it will be the responsibility of staff in maternity services and hospital's board executives to urgently act on warning signals so problems can't be ignored or delayed.”

One of the first places to pilot the new signal system was Cambridge University Hospitals NHS Foundation Trust.

Cathy Bevens, lead safety and governance midwife, Cambridge University Hospitals NHS Foundation Trust, said: “We have had really positive experiences using the signal system – colleagues feel like we are being responsive. The system and safety check brings us together as a team and makes us really focus on what the issues are and where care can improve. It's encouraged senior leaders and executives to come and talk to staff and services users, to listen their issues and concerns. This has prompted a building of trust and teamwork, and acknowledgement of the lived experiences of women on the labour ward. Overall, a really positive experience.”

Health chiefs say the early signal system being visible at all levels will help to encourage a positive culture within maternity services, where safety concerns are identified and addressed openly.

MOSS was created by the NHS as a direct response to a recommendation in the "Reading the Signals" report, following the independent investigation led by Dr Bill Kirkup on maternity and neonatal services in East Kent. The recommendation was for the creation of a system, which could "identify valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for national mandatory use.

The development of MOSS was led by an expert group including Dr. Bill Kirkup and Professor David Spiegelhalter, a leading authority on statistical risk, as well as families and service users.   

Dr Bill Kirkup, said: “This is a really positive development that originated directly from the investigation into East Kent maternity services.  The families there who did so much to bring this to light deserve great credit for the improvements it will bring.”

Chris Binnie is a national service user representative with the maternity neonatal programme at NHS England. His son, Henry, was stillborn at 38 weeks in 2014 as a result of undetected intrauterine growth restriction.

Chris, said: “The culture of curiosity that MOSS enables gives maternity services the opportunity to learn well and to drive through change. 

“This is hugely important to service users and can help prevent the tragedy of avoidable stillbirths and neonatal deaths happening to families in future.”

Other parts of the health sector which uses a safety signal, include children's cardiac services and paediatric intensive care, which use cumulative sum control chart methodology – a statistical analysis used to detect trends in rare but serious events to improve outcomes.

MOSS applies this approach to maternity with a specific focus on intrapartum care safety.

Clea Harmer, Chief Executive, said: “Early detection of serious safety issues is vital in saving babies' lives so it's very important that all maternity services have access to this data and that boards have oversight and act swiftly on any concerns flagged by the Maternity Outcomes Signal System (MOSS). 

"This rollout is a welcome step to improve safety monitoring across NHS maternity services and it's encouraging to see recommendations from Reading the Signals being implemented, reinforcing the importance of learning from data to drive continuous improvement in maternity safety.”

The rollout of MOSS is part of NHS England's wider support - such as a Perinatal Equity and Anti-Discrimination Programme – for maternity units' ongoing work to improve maternity and neonatal care for mothers, babies and families.