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Delay/Failure in Care or Treatment: St johns' ambulance unable to transfer to BCH for MRI scan.  Day 5 newborn screening taken but left in the drawer.

Clinical Equipment: CVL leaking.  ECG machine was not working.

Access to Services: No St Johns ambulances available for MRI scan x3.

Documentation/Information Governance:  Triplets born but unable to admit until 3 hours post birth.   Outpatient ROP screening booked incorrectly.

Patient Tests and Scan issues: NIPE not completed.  SBR taken in community baby admitted to TC bilirubin below the treatment line.

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Medication and other administered products: Frequency of meropenem not correct for gestation. Incorrect concentration of sodium and potassium running peripherally rather than centrally. IV antibiotics given late.

Access to Services: MRI booked but St Johns have no availability to transport. Baby noted to not have a follow appointment booked. Datix to record over capacity.

Other Clinical Incident: Preterm delivery at QE hospital. X3 datix for St John’s ambulance not available for MRI bookings.

Delay/Failure in Care or Treatment: Baby discharged without repeat newborn bloodsport screening for SCID. Bloodspot screening taken but not sent. Baby discharged from postnatal without NIPE.

Cardiac/ Respiratory Arrest, ALTE: Sadly 2 babies passed away. Baby required chest compressions following PICC line extravasation.

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Medication and other administered products: Rota virus vaccine given which was not due.  SMOF was put up instead of intralipid syringe.  Glucagon found to be clamp at handover.

Access to Services: MRI booked but St Johns have no availability to transport. Suspension of the 27-week pathway.  No PICU capacity so surgical babies transferred out of region.

Clinical Equipment: Limited stock of in-house incubator circuits.  Premicath snapped at the hub, Premicath leaking near the hub.  No size 6 inline suction catheters.

Delay/Failure in Care or Treatment: Day 28 repeat newborn screening not completed on discharge. NIPE not completed prior to transfer to TC.

Cardiac/ Respiratory Arrest, ALTE: Sadly 5 babies passed away.

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Resus audit 2026 - Please remember if you have completed a check to ensure you sign for this in the folder.

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Resus audit 2025

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ATAIN Admission rate 26-27

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ATAIN Admission rate 25-26

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Thank you Alicia for your hard work and support as student co-ordinator

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Thank you Charity for your hard work and support within the Clinical Governance Team

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Thank you Maggie for your support with the launch of the brain protection bundle.

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Thank you Robyn for your support with the launch of the brain protection bundle.

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Well done Rosy! what lovely feedback!

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Thank you Jasmine for your continued hard work and excellent professionalism and support.

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Thank you to sharlet for your support with the launch of the brain protection bundle.

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Thank you to everyone for your continued hard work and support to our families. Some special mentions go to Sarah, Kayleigh, Keleigh, Katie, Sonia, Hafsa, Karen and Jess.

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Thank you Becky for your support with the launch of the X-Tag system

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Thank you Meg for your support with the launch of the X-Tag system

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Well done Toni! What a shining example of how a thorough handover is completed.

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Well done Deb for all of your support and hard work with the NNAP data.

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Well done Chris for showing excellent professional attitude and manner when on your NTS shift.

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Well done Jenny for supporting the IFT during staffing shortages.

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Well done Jordanna for supporting this family in a very distressing time.

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Well done Matt Nash for being excellent support to this family

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Well done Matt Nash for being a great support to the wider team

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The primary reason for admission in our term babies has consistently been respiratory distress closely followed by suspected sepsis/failed pulse oximetry.

Majority of the time this is a result of a delayed transition and has quickly resolved. Learning from ATAIN reviews suggests commencing on low flow oxygen and escalating upwards as required.

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The primary reason for admission continues to be respiratory distress, interestingly all other reasons are alot lower so far in 26-27 this may be due to the individual catergorisation when assessing each case.

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Patient Tests and Scan Issues: Ultrasound machine not pulling through echo images to EPIC.  Date of sample not on newborn screening.

Access to Services: St Johns ambulance not available for transfer.

Medications and other administered products:  Vial of IV morphine found to be unopened but empty.

Clinical Equipment: Cooling wrap leaking.

Delay/Failure in Care or Treatment: KP score entered incorrectly which led to delay in giving antibiotics to baby.

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Medications and other administered products:  TPN expired and had to be discarded as longer expiry dates used first.  Medication prescribed to the wrong patient, noticed straight away.

Clinical Equipment: Cooling wraps leaking.  All 3 nitric machines in use.

Cardiac/Respiratory arrest, ALTE:  4 deaths.

Delay/Failure in Care or Treatment: Bilirubin level not plotted therefore treatment not started.

Feeding issues: Wrong breast milk given to baby by student nurse.  Baby fed the wrong formula.

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Red Black Playful The Power of Habits Poster (1)

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Perinatal Quality and Safety Report to Board November (October Data)

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BWH NNAP data for 2024

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November 2025

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Well done Keleigh for using your intiative to advocate for your patients and their care needs.

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Well done Iqra for your calm and controlled manner during an emergency situation.

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Well done to Ammaarah for showing such lovely support to your colleagues and this family through a very difficult reorientation of care.

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Well done to Catriona for advocating so well for your patient and their family.

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Well done to Alecia for advocating so well for your patient and their family.

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Well done to Emily and Hannah H for showing such compassion and empathy to this family.

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Well done Dr Okolie for your calm and controlled manner during a busy resus.

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Well done to Manobi and Annie, for making this families neonatal experience a lovely positive one!

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Well done Sonia! Thank you for all of your supportive hard work!

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Well done Jordanna thank you for ensuring your docummentation is excellent and clear!

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Well done Ellie, this is such a lovely, kind and compassionate gesture to help a new member of the team feel included!

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Well done Ijaz for your hard work and support during a busy shift!

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Well done Katie! Your hard work to support all of our expressing mum's, doesn't go unnoticed!

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Well done Molly, thank you for using your initiative to support the wider team!

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Thank you Jordanna for being an excellent role model and example to junior staff and our aspiring workforce!

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Well done Dianne for helping to support the PERIPrem project!

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Well done Rachel and Kelly for helping to support the PERIPrem project!

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An excellent example of great team working and use of clinical knowledge and initiative to provide excellent care for your patient! Well done Lauren!

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Thank you rachel for showing such empathy and compassion to this family during a really diffcult time.

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Thank you to Gill for your kindness and compassion shown is such a difficult situation!

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Well done Katie for helping to support the PERIPrem project!

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Well done Jade in helping to support the PERIPrem project!

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Well done dora for helping to support the PERIPrem project!

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BWH NNAP data for 2023

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Well done to all! Excellent team work shining through as always.

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Well done Nancy, this was a great example of excellent work to avoid separation between mum and baby!

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Well done Emma, a great example of going above and beyond to provide excellent care for your patient!

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Well done Flo! The true definition of being an excellent role model! Keep up the amazing work.

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EPIC Issues

If you have any issues with EPIC EPR, please seek support with our Super Users in the first instance. If they can not help, please raise a IT ticket and let the matrons know.

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Well done Toria! You showed excellent leadership skills and made a very busy shift smoother for everyone!

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-NNAP audit data tells us our NEC rates and normothermia rates are higher than expected... how can we help improve this?

Thermoregulation monitoring following delivery

The use of servo mode on our extreme preterm population

Early breast milk administration within 6 hours

Supporting mothers to express within 2 hours of delivery

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Anyone can get involved with mortality reviews, please let Clare or Katie know if this is something you would be interested in.

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Well done Helen! You showed a calm and clear thought process in a very stressful situation! Keep being amazing!

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Governance Leads:

Clare Atkinson - Clinical Governance Lead NICU Ext 5202

Katie Wood - Clinical Governance Lead NICU Ext 5202

Cecilia Perez Fernandez - Consultant Governance Lead

Hannah Wood - Consultant Quality Improvement Lead

Sarah Ellis - Governance Matron Ext 5228

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Link Workers:

Dora Reeves

Jordan Chandler

Romarni King

Terri Field

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Mortality team:

Lucy Green - Consultant Mortality Lead

Matt Cawsey - Mortality Consultant

Gill Preston - Mortality Consultant

Hannah Wood - Mortality Consultant

Manobi Borooah - Mortality Consultant

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What is the risk register?

A risk register is a tool used to document and manage potential risks on the NICU, helping to identify, analyze and mitigate these risks. It is an integral part of risk management and centralizes risk information and helps to assist with decision making and ensures accountability.

All datix's relating to any risks on the risk register will be linked to the risk to gather evidence to support the need for change in practice or to further manage the risk.

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NICU's current active risks:

A risk to the provision of safe care due to insufficient number of senior medical workforce.

If there is limited neonatal specific care at BCH then this could impact on neonatal outcomes.

If NICU do not meet BAPM standards (with regards to QIS nurses) then we will have an unbalanced skill mix.

If we do not improve thermoregulation for babies less than 34 weeks then there is an increased risk of mortality.

If there us not an adequate inpatient non-emergency transport service, then patient care is compromised.

If procurement processes and controls are not amended in NICU there is a financial risk to the trust.

If we do not improve the rates of NEC for babies less than 32 weeks then we might remain outlier for this measure.

Inability to perform GI contrast studies at BW resulting in delayed diagnosis, treatment and poor patient and family journey.

If the main corridor floor on the Neonatal unit is not replaced it may continue to erode causing structural damage

If the decontamination room is not upgraded then there is a risk to further infections on the NICU.

If we do not reduce rates of blood stream infection in babies less than 32 weeks then there is an increased risk of mortality

If the location of TC remains then there is an increased risk in keeping the staff and patients safe.

If there is no on-site radiology cover out of hours leading to delayed imaging, diagnosis and treatment.

If the floor is not repaired then there is an increased risk of infection outbreak on the neonatal ward.

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If you have previously been able to log into Datix and it has stopped allowing you to please report to IT in the first instance and ask them to check if your active directory account is correct.

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Well done Kai! You showed excellent forward thinking and utilised the routine enquiry questions to ensure mum and baby were safe.

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Well done Sonia, showing excellent escalation and advocacy for her patient!

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Well done Romarni! Outstanding escalation of concerns and compassion shown to this family!

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Well done Chloe! Amazing leadership and escalation of care!

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Thank you Carol and the HCA team! You all showed excellent team work and forward thinking to keep the service running!

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Well done Courtney! Your excellent knowledge and support clearly helped this family to understand their baby's feeding cue's and readiness better!

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Well done Jasleen! An exceptional role model to her peers!

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Broken Equipment

How to report:

Clean the item

Place smaller items on middle desk, large items place in isolation area near the resuscitaire

Call medical engineering on 8555 to report. During working hours, they will collect immediately. Out of hours, leave a voicemail and they will collect during working hours the following day. Please state what the equipment is, it's asset number (on the yellow label), what is wrong with it, and where it is located.

Leave a note on the equipment stating that it is broken and date it has been reported.

There is no home for broken equipment. Do not leave in ladybird or incubator room. This is to prevent non-reported equipment from accumulating and resulting in patient safety events.

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BWH NNAP data for 2022

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Well done Lauren! Excellent work and compassion.

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Well done Flo! lovely feedback and such an exceptional role model!

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What are the 11 PERIPrem Interventions?

Birth in the right place

Antenatal Steroids

Magnesium sulphate

Intrapartum antibiotics

Optimal Cord Management

Thermoregulation

Volume targeted ventilation

Caffeine

Early breast milk

Probiotics

Prophylactic hydrocortisone

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Clinical Equipment: POCUS scanner found unplugged in corridor with gel still on the probe.  Equipment shortage of arterial transducer lines.  2 x cooling wraps leaking.

Delay/Failure in Care or Treatment: Episode of hypoglycaemia was not escalated.  Tongue tie not detected on NIPE.  Delayed diagnosis of imperforate anus.

Medications:  Gentamicin level taken post administration instead of pre-dose.  SMOF lipid running instead of intralipid.

Patient Tests and Scan Issues:  Baby discharged at 6 days with no newborn screening completed.  No day 0 sample taken on baby who needed a blood transfusion.

Pressure Injury:  High flow prongs left indent in baby’s skin.  Blood pressure cuff left indentation.

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Well done Rosy, what such lovely feedback!