16 Aug Report identifies actions to improve open disclosure in England’s NHS maternity services when babies die or are harmed
Home › News & insights › Latest news
16 August 2024
Report identifies actions to improve open disclosure in England’s NHS maternity services when babies die or are harmed
A new study looking at the experiences of families and healthcare professionals following incidents involving NHS maternity care highlights critical factors for improving communication with families.
The team, which included family and charity representatives as well as ARC researchers at King’s College London, hopes the findings will drive improvements in open disclosure in a way that best supports both families and healthcare professionals.
What is open disclosure?
Open disclosure is when the NHS informs families that the care it has provided has directly caused harm. It should provide patients and families with honest answers and ensure healthcare providers learn from mistakes to prevent them from happening again.
The new study, called DISCERN, aimed to understand whether NHS maternity services in England involved families in investigations and reviews surrounding incidents, what worked well, what didn’t, and why. The findings were published in Health and Social Care Delivery Research.
Artwork by May Kindred-Boothby, Woven Ink Studio Ltd.
Five critical factors to improve open disclosure
Building on hypotheses from previous research, the report identifies five critical factors to improve open disclosure in maternity care following incidents that caused harm or death to the baby or woman:
Meaningful acknowledgement of harm to the family
The opportunity for family and staff to be included in reviews and investigations of care
Possibilities to make sense of what happened
Care from clinicians who feel safe and skilled to disclose and discuss harm
Knowing that changes are happening in that service
Research team & collaborators
Co-led by Mary Adams (Visiting Senior Research Fellow, KCL) and Professor Jane Sandall CBE (KCL), with collaborators at King’s College London, Sands, BirthRights, University of Manchester and the Birth Trauma Association. Funded by the NIHR Health and Social Care Delivery Research Programme.
Learning from parents, families and healthcare professionals
The national study was carried out over three years and in three phases:
Review of documents related to safety, incidents, harm, reviews and investigations in maternity care, plus interviews with stakeholders and families
Case studies of three maternity services, including interviews with staff and families, and observation of staff and family meetings and informal unit activities surrounding open disclosure
Interpretation of findings in family, clinician and manager forums to develop actions to drive improvements
“The most important people to involve in these investigations are the parents — they have to be central to the whole picture. Without their perspectives of what happened, we’d never be able to learn, and to change care for other families.”
Healthcare professional interviewed as part of the DISCERN study
The team concluded that there is a need for:
✓
Service-wide systems that place injured families at the centre of open disclosure processes
✓
Training and post-incident care to support clinicians
✓
Ongoing conversations with families following the incident
“What we found was that in these NHS trusts, good practice surrounding open disclosure wasn’t systemic, but dependent on staff members’ ability to have, and experience with having, difficult conversations with families. The key issue is how do we make these processes part of standard care, and how can we best support staff to have these difficult conversations.”
Professor of Social Science and Women’s Health, King’s College London; ARC South London maternity and perinatal mental health theme lead
The DISCERN film
As part of the DISCERN study, the team created a film intended to improve staff awareness of what is important to families and how interventions can be improved. The film focuses on areas of good practice in open disclosure and draws on the experiences of families and staff involved in incidents of harm.
“This thought-provoking and incisive animation is a ‘must watch’ for all healthcare professionals working in maternity services. It captures the emotional turmoil of families who have suffered harm, in their own words. It explores the feelings of healthcare professionals who must navigate the difficult challenge of disclosing the harm in a way that does not add to the family’s trauma. Used in training and education it will go a long way to preventing even further emotional harm to all those involved in these incidents.”
Co-founder, Birth Trauma Association
📄
Read the full report
Adams MA, Bevan C, Booker M, Hartley J, Heazell AE, Montgomery E, et al. Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study. Health Soc Care Deliv Res 2024;12(22).
Related content
- →
About the DISCERN study — open disclosure with women and families after unexpected harm in NHS maternity care - →
DISCERN study website - →
Sands: The DISCERN study - →
Maternity and perinatal mental health research at ARC South London
References
[1] Sands. The DISCERN study. sands.org.uk (accessed August 2024).
[2] Adams MA, Bevan C, Booker M, et al. Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study. Health Soc Care Deliv Res 2024;12(22). doi:10.3310/YTDF8015
Original source: arc-sl.nihr.ac.uk — NIHR ARC South London legacy content archived May 2026.