The CQC found variability across trusts in
the different teams that would receive a copy
of alert forms. Discussions and actions of the
multidisciplinary care teams were not always
copied into the maternal handheld records.
On one visit, the CQC identified a lack of
any antenatal clinical notes in newborn babies’
notes, including scans. This is a patient safety
breach and an illustration of how such lapses
can have a knock-on effect in the care process
and lead to adverse events.