The CQC found the overall screening and
referral process to be relatively robust, with
clear national guidance on screening for the
11 specific physical and genetic anomalies and
conditions as part of the NHS Fetal Anomaly
986 British Journal of Nursing, 2016, Vol 25, No 17
© 2016 MA Healthcare Ltd
Screening Programme. The report also calls
for clarity about what happens when other
anomalies are detected or suspected. Not
all trusts visited by the CQC had written
guidelines on the screening and referral
pathways for fetal anomalies. Communication
around the management plan for mother and
baby was variable across the trusts.
A main cause of litigation and patient
complaints is in the area of communication
failures. Often, errors that occurred
would never have happened had proper
communication strategies been in place. It
is very worrying to read that sharing of
information about risks is not as good as it
could be in this care area.
The report also found that there was
variability in the way that trusts flagged risks
such as fetal anomalies in the maternal record:
‘Some trusts used a sticker on the front
of the maternal record. However, one
tertiary centre identified this as a risky
approach, since many cases involved
risks and if there was a failure to use a
sticker, staff may not check the record
for risks. They decided it was safer
to always check the detail within the
maternal record.’
CQC, 2016: 12
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.
Aspect 2: identifying and