Investigation Reveals 999 ‘Postcode Lottery’ of Pregnancy Care

An investigation has revealed that pregnant patients, calling 999 for help whilst waiting for an ambulance, are given different instructions by call handlers depending on their location.

A report, undertaken by the Healthcare Safety Investigation Branch (“HSIB”), was published on 17 February 2022 following an investigation to help improve patient safety, concerning advice given to pregnant patients waiting for an ambulance due to a maternal emergency. 

The HSIB reviewed an incident whereby a pregnant patient telephoned 999 and was given advice by a non-clinical call handler. The mother subsequently suffered a placental abruption and lost a large amount of blood, and both she and the baby required a significant amount of care. 

The HSIB investigation into that case identified aspects of the pre-arrival instructions, given by call handler, were not in line with maternity guidance. This created a risk of harm to both pregnant patients and their babies. 

Sadly, the HSIB identified 15 further cases where similar concerns were identified, which prompted this national investigation.

The HSIB also discovered that there are two different triage systems being used by 999 operators in England, meaning two patients in different locations, with the same clinical emergency, would be provided with differing advice. The HSIB considered this created a ‘postcode lottery’ of care for pregnant women, which could have disastrous consequences for expectant mothers and their babies.

A number of safety recommendations were made by the HSIB, including guidance which should be developed for maternity emergencies in the non-visual, non-clinician-attended environment. A further recommendation noted that a regulatory mechanism should be identified to provide formal oversight of 999 maternity pre-arrival instructions for NHS provided care in England. It was also recommended that patient safety incident investigation standards should be developed to further support cross-boundary investigation.

If you have concerns about the maternity advice and care you have received, or any other type of treatment, please get in touch with our team who will be able to assist you sensitively.