In ‘Resolution through collaboration’, NHS Resolution’s 2025-28 Strategy, our second strategic priority is to contribute our unique data and insights to learn from harm and our third is to support maternity and neonatal safety improvements. Aligned with these aims we have gathered together learning from our Early Notification Scheme and produced a number of case stories to help support learning from harm identified through claims.
Our case stories are illustrative and based on recurring themes from real life events. These experiences have been highlighted and shared with you, to help identify potential risks in your clinical area, promote learning and prevent fewer incidents/claims like these occurring in the future.
We have also produced a case story guidance document which explains the various ways you can use the case stories, from individual self-directed learning to support continuous professional development to using them in a team environment. We have had feedback that some Trusts use the case stories as part of multidisciplinary mandatory training such as Drills and Skills/In situ simulation and also use them to support teaching for student midwives/medical students. The idea is that by learning from the experience of others, maternity unit staff will be able to change their approach to care.
Read our latest Early Notification case stories:
- Maternal Multimorbidity
- The role of pre-hospital care in maternity cases
- Suspected ‘large for gestational age’ baby
- Identifying and assessing risk factors to facilitate informed decision making in maternity care
- Consideration of meconium as a risk factor in labour
- Placental abruption
- Communication and language challenges when English is not a mother’s first language
- Fetal growth restriction
- Good practice: Optimising care in neonatal hypoxic ischaemic encephalopathy
- Induction of labour
- Chorioamnionitis after prolonged rupture of membranes at term
- Good practice: care outside of guidance after previous caesarean
- Language and digital barriers to accessing maternity care and advice
- Obstructed labour
More case stories available to read below:
- Recognising and avoiding significant maternal and neonatal hyponatraemia
- Good practice in managing umbilical cord prolapse
- Neonatal hypoglycaemia
- Management of hyper-stimulation and fetal bradycardia
