A Series: COVID-19 and its Impact on the NHS - Obstetrics

A Series: COVID-19 and its Impact on the NHS - Obstetrics

Introduction

In our next instalment looking at the effect of Coronavirus on the NHS we explore the area of medicine that cannot be delayed by pandemic nor pandemonium, obstetrics.

In a healthcare crisis that has spanned over 12-months it was inevitable that women would come to term during the pandemic and require the services of the NHS to safely deliver their baby.

In this article, THEMIS explores how COVID-19 has affected the provision of these services, the adaptations implemented to enable these and the potential implications of these on future care and litigation.

Obstetrics and COVID-19

Even without a pandemic, Obstetric wards are often one of the busiest wards within a hospital. They provide a critical service in the life-changing event of childbirth and are crucial to the running and maintenance of public health. During a pandemic, this has not changed.

Unlike elective procedures, which can often be delayed safely, when a pregnancy comes to term there is nothing that can be done to push this back further. When the child is ready to be born, COVID or not, Obstetric care is required.

This has led to Obstetricians having to be able to perform their duties whilst also taking into account the spread of a global virus. In light of this, THEMIS have interviewed practicing Obstetricians to explore what issues have arisen as a result of the pandemic and how patient care has had to adapt to maintain safety and healthcare standards.

Litigation Risk & Recommendations

Following our discussions with frontline Obstetricians during this time the following areas of risk have been identified:

1. Delays/Non-Attendance

The primary issue that became apparent was the reluctance for mothers-to-be to attend hospital for routine follow-up and scans. With the prevalence of COVID-19 in hospitals going up, THEMIS have discovered that a significant number of pregnant women were putting off having scans or attending hospital for antenatal assessments. As a result, some patients have unfortunately had a decline in both their own health and that of the foetus, leading to limited care options from practitioners further down the line.

This issue was then compounded by the systematic reduction in appointments across the NHS, including those appointments for prenatal and antenatal women.

Reductions in staff due to positive COVID-19 cases or isolation as well as other COVID measures (such as redeployment) meant that throughout the pandemic there has been a knock-on effect leading to remaining practitioners to cover even more patients than usual. This led to a reduction in available appointments in an environment when mothers were less likely to attend these in any event.

Unfortunately, this combination of factors lead to care concerns including a COVID-19 related claim seen by THEMIS relating to a failure to provide appropriate care for a ‘timely’ termination of pregnancy as a result of ultrasound scans being delayed and initial consultations being conducted remotely.

Recommendations

Having considered these cases with our Governance Team and partners at TMLEP we suggest the below recommendations:

1) Clinicians should bear in mind that many patients have felt, and will likely continue to feel, some level of hesitance when needing to attend hospital, even if urgent, due to the risks of COVID-19. THEMIS recommends that patients are counselled on the benefit of attending appointments when needed and reassured that there are COVID-19 safety measures in place to protect patients and practitioners alike.

2) Whilst delays in this climate are inevitable even with a vaccine rollout, patients should be routinely informed of any and all delays they may face whilst receiving care. By reassuring patients and keeping them well-informed, risk of litigation can be reduced.

2. Adapted Practices

Since March 2020 new practices and safety measures have been implemented within care settings to better protect practitioners and patients alike from COVID-19 whilst still endeavouring to offer the required standard of care to those who needed it.

Within the Obstetrics department, one of the many changes included reducing the amount of time expectant mothers spent within the hospital itself, leading to many procedures and checks being adapted or forgone.

Pre-COVID-19, expectant mothers would be induced as an in-patient, under the careful watch of practitioners. However, unfortunately, this practice had to adapt to reduce the risk of COVID-19 spread. Instead of in-patient care, out-patient balloon inductions were used, so that patients could spend more time with their birthing partners. Whilst this type of adapted practice was a requirement following COVID-19 rules and regulations, this increased the risk of foetal death due to a lack of continued, in-patient review/assessment whilst the patient was at home.

Claims analytics already emerging show that claims are already being brought due to the use of out-patient balloon induction and therefore a lack of foetal assessment during this period.

Recommendations

  1. As COVID-19 measures within hospitals will likely stay in place for the time being, THEMIS recommends clinicians weigh up the benefits of limiting in-patient time against the risk of COVID-19 spread. As the vaccine rollout flattens the spread and the risk of transmission is reduced, clinicians need to take specific care in their decisions about whether a patient should be an inpatient and whether outpatient balloon inductions are necessary. Well documented decision making is key in this area in responding to any potential claims regarding this adapted aspect of Obstetric care.

Concluding Comments

Pandemic or not, women will continue to need Obstetric services and given the catastrophic effects of issues, the standard of care has to be maintained come what may.

Having to handle the COVID-19 pandemic has allowed new processes to be devised should a future disease outbreak cause similar disruption, however, clinicians should be mindful of the litigation risk and recommendations outlined above to ensure they and their patients are protected.

References

  • Co-authored by the THEMIS Clinical Defence Publishing Team, Ms Kayley Newman and Mr Alexander Acaster.. (2021). A Series: COVID-19 and its Impact on the NHS - Obstetrics. The THEMIS Clinical Defence Case Studies. 1 (4), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.