Early Notification case stories
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 perinatal 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.
This module contains 14 learning resources.
Case story
Maternal Multimorbidity
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
The role of pre-hospital care in maternity cases
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Suspected ‘large for gestational age’ baby
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Consideration of meconium as a risk factor in labour
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Placental abruption
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff.
Faculty of Learning resource
Case story
Communication and language challenges when English is not a mother’s first language
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Fetal growth restriction
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Good practice: Optimising care in neonatal hypoxic ischaemic encephalopathy
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Induction of labour
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Chorioamnionitis after prolonged rupture of membranes at term
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Good practice: care outside of guidance after previous caesarean
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Language and digital barriers to accessing maternity care and advice
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Recognising and avoiding significant maternal and neonatal hyponatraemia
This case story is illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: • …
Faculty of Learning resource
Case story
Management of hyper-stimulation and fetal bradycardia case story
This case story is based on real events and NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. As you read about this incident, please ask yourself: Could this happen in my organisation? …
Faculty of Learning resource
