NHS maternity dashboard launched to prevent tragedies

A national dashboard is being rolled out across NHS maternity services to help spot serious safety issues and prevent neonatal tragedies.

The Maternity Outcomes Signal System (MOSS) sends out a warning signal if it detects a pattern or trend in maternity data which seems out of the ordinary. 

Wes Streeting, health secretary, announced the creation of a dashboard in June as part of a national investigation into maternity and neonatal care, following a series of high-profile failures across several NHS trusts.

Retrospective analysis shows MOSS would have detected signals in maternity units that experienced serious incidents, including East Kent, Shrewsbury & Telford, Leeds, and Nottingham.

Duncan Burton, chief nursing officer for England, said: “There have been too many times where safety issues in maternity could have been detected earlier, and we have seen the devastating impact this has had on families.

“Having a signalling system for maternity which can carefully look at data in near real-time and spot early warning signs if something is potentially going wrong will help to avert safety incidents and prevent tragedies.

“It is the first national system of its kind in maternity to be able to signal potential safety issues as they emerge and allow them to be acted on faster by maternity services.”

MOSS was created in response to a recommendation in the ‘Reading the signal‘ report, published in October 2022, following the independent investigation led by Dr Bill Kirkup on maternity and neonatal services in East Kent.

Its development was led by an expert group including Kirkup and Professor David Spiegelhalter, an authority on statistical risk, as well as families and service users.   

Kirkup, said: “This is a really positive development that originated directly from the investigation into East Kent maternity services. 

“The families there who did so much to bring this to light deserve great credit for the improvements it will bring.”

Once the MOSS system generates a signal, the maternity unit must carry out a critical safety check within eight working days and share the action taken with regional and national teams.

Signals will be traffic-light coded, with amber alerts representing 95% confidence and red alerts representing 99% confidence that the increase in events needs urgent attention.

Cathy Bevens, lead safety and governance midwife, Cambridge University Hospitals NHS Foundation Trust, which piloted MOSS, said: “The system and safety check brings us together as a team and makes us really focus on what the issues are and where care can improve.

“It’s encouraged senior leaders and executives to come and talk to staff and services users, to listen their issues and concerns.”

Data and signals will be visible at a trust, integrated care board, regional and national level to ensure that concerns are acted on quickly.

Clea Harmer, chief executive of of the charity SANDS, said: “Early detection of serious safety issues is vital in saving babies’ lives so it’s very important that all maternity services have access to this data and that boards have oversight and act swiftly on any concerns flagged by the MOSS.”