Context: the triumph of protocol over common sense

Hospital-based and community midwives are critical players in the identification of women who may be at risk during pregnancy from, for example, substance, or domestic abuse and also are often the first professionals to identify potential danger to an as yet unborn infant. The midwives differ from many other professionals in the system in that their relationship with the women with whom they work extends over time and their knowledge of the women’s personal and social circumstances can be considerable. This contrasts with ‘brief hospital encounters’, though there can be a downside, as one senior practitioner astutely observed:

[S]ometimes if you work in areas of high social deprivation and you’re in and out of houses all the time where standards may be, for example physical cleanliness levels or interaction with children are very poor. It can start to feel a bit normal to you. You can normalise because you’re not seeing the wider picture. I don’t think that happens straight away but it does happen if you’re working in those areas for prolonged periods. You sort of, it’s almost like your thresholds for acceptability reduce down a little bit too much.

Specialist midwife (MW6)

Knowing women over extended periods, midwives are in touch with changing circumstances over the course of the pregnancy, potentially altering the nature of the midwife’s relationship with the woman. Self-evidently, newborn infants are also at particularly high risk of harm if their basic care needs are not met, or if they are injured accidently or non-accidentally. Thus, midwives are likely to encounter a considerable number of ‘special circumstances’, knowledge of which they may wish to share with other agencies, including CSC. The complexities are exacerbated by the fact that CSC do not usually accept referrals relating to unborn infants until 18–20 weeks of gestation.

The SCF for Pennine was the subject of a design project initiated during the course of the research. There were two key aims: first, to replace the paper forms with an online system, and second, to review and revise the criteria which triggered the production of these forms. An important advantage of an online system would be to simplify the logistics whereby the forms were incorporated into the patients’ hospital notes. It is clearly critical that this information is available to hospital staff when the woman is admitted for delivery, and, to ensure that they stand out in the notes, the forms are printed on yellow paper. However, the forms are completed by midwives in the community, and to ensure that they are lodged in the notes the midwife must physically transport them to the relevant hospital, filing them by hand in order to alert attending staff when the woman presents in labour. This is evidently time-consuming, and by obviating the need for such a journey, the online system should bring real benefits, as the following interview extracts with two community midwives attest:

We do a special circumstance form for ladies’ case notes. It’s a yellow form that gets entered into the notes. It’s going to be going online soon which is going to be a bonus for us because the problem we have now at [location] is the lady’s case notes are kept here until she’s 28 weeks then they get sent to Oldham. So if we have got to update these forms we have to drive to [location], park up, walk a million miles to just write in the notes. So it’s going to be online so the updates can be done online which will be much, much better.

Community midwife (MW5)

We’re going online with the system and I think being online if we have to update somebody’s notes we have got to where the case notes are held so it’s often difficult trying to actually get to, you know, so I think once it’s online that will be better, things will be updated live rather than a few days later when you get the opportunity to do it.

Community midwife (MW7)

A more fundamental problem with the ‘yellow forms’ is the progressive lowering of thresholds since the form was first introduced; originally, these were produced only for serious cases, but now they have become the norm:

[A]t one time when we started off the system of the yellow form we used to call it, if someone had a yellow form in their notes it was a big you know, big deal – ‘She’s got a yellow form. She’s got a yellow form’ and a report was always handed over – ‘She’s got a yellow form’ and the circumstances. But now it’s almost become a bit of a sort of standing joke in midwifery that ‘Oh what, she hasn’t got a yellow form?’.

Specialist midwife (MW6)

‘Cos years ago those yellow forms – we have had them quite a long time but they were only done for serious cases. But it’s as these lists come up, you must do them for this, this, this and this, that’s when it becomes, it’s not a big deal any more . . . It’s not like an alert – ooh you know, just check that out. So if they could change that, that would be better because you could have the yellow for the serious ones, the ones that really need concern but then a different colour for the ones that are a history of, just watch out kind of thing.

Community midwife (MW5)

The senior midwives we interviewed, mainly team leaders, provided numerous examples of situations where special circumstances were produced needlessly:

But the trouble with these yellow forms are the form is done for anybody with a history of depression for example. So say I was 16, my mother died, I was going through my GCSEs [General Certificate of Secondary Education] and I was depressed, I would have a form done. I’m now 30 years old, pregnant and in a happy marriage. It’s not relevant any more. Yes the history’s there but there was a reason for it. And I’ve now passed through that. I’m happy. There’s no problem. Yet she gets a form.

Community midwife (MW5)

So is the fact that someone’s had postnatal depression 2 years ago, is that going to change – but she presents as well today – is that going to change the way that you manage her care? . . . So therefore I would not generate a special circs [circumstances] form ‘cos it’s a paper exercise and it’s not actually doing anything to improve that patient journey. . .

Specialist midwife (MW6)

I mean my issue is with special circs [circumstances] is that we do a special circ for everything. And I think we have got to be realistic that not everything needs to be documented. There are things that don’t need to be documented. Depression that they had 20 years ago doesn’t really need to be documented if it was treated, dealt with and there’s been no reoccurrence.

Community midwife (MW8)

Defensive practice was driving the reduction in thresholds and broadening of categories, in the view of senior professionals:

But this fear that it’s not a case of ‘I know somebody who that happened to and they happened to in court’, it’s just like just to be on the safe side, so it just becomes a paper trail . . . a lot of special circs forms are generated for that reason and that’s what we need to clarify in the trust I think.

Specialist midwife (MW6)

MW6, a specialist in mental health, saw this symptomatic of a more general cultural shift:

And I think there’s a growing culture amongst health professionals generally of being afraid of not referring, of overlooking and there’s a growing culture of referral for purposes of covering one’s own back as opposed to a referral because you believe that it’s in the best interests of the patient that you’re looking after . . . And what that does for the women that I look after is just cause unnecessary anxiety and is a fruitless process a lot of the time.

Specialist midwife (MW6)

The categories and criteria for which a SCF is deemed appropriate have thus become too broad. SCFs can cover a wide range of issues with no sensitivity to current assessment of risk. Too many are being completed and this is creating a problem in differentiating between levels of risk and danger.

I think we’re getting into the realm of erring on side of caution all the time and we’re doing them all the time for everybody and that’s my real issue. I get 20, 30 referrals a week which when you have to go through that . . . by the time I’ve gone through all them the time I’ve spent and I’ve reduced it down so much the amounts that really are not necessary, we spend more time doing that bit rather than looking at the ones that really are an issue and they’re the ones that can easily be missed.

Community midwife (MW8)

It gets bigger and it grows. It’s just like practices sort of mushroom really in hospitals very quickly and before no time at all something has become routine-ised that was not routine-ised. The referrals are up so there’s two ways of looking at it. People say we are getting so much better at detecting where there’s child protection issues now ‘cos we generate all these special circumstances forms. We’re getting much more vigilant about safeguarding . . . I think some of us think are we just generating a load of forms that we don’t need.

Specialist midwife (MW6)

Once that culture’s developed it’s really hard to unpick it because a lot of the people who were doing it are doing it with good intention and they maybe are genuinely fearful that they don’t want to overlook something. But in that process we have lost our capacity to actually see what’s in front of us a little bit. It’s a recent thing I think. I would say it’s probably in the last 4 or 5 years that I’ve noticed there’s a definite shift away from, sometimes it just feels like the triumph of protocol over common sense.

Specialist midwife (MW6)

The table-top meeting

The design of the online system was progressed over 2012, with the aim of launching the system in the spring of 2013. The team attended a key ‘table-top’ design meeting in November 2012 which directly addressed the issues noted above. Attendees at the meeting included the Head of Safeguarding (HS), the named nurse for safeguarding (NN), the Head of midwifery (HM), a senior hospital midwife (SM) and two community midwives (CM1, CM2). The first part of the meeting considered the logistics of filing the electronic forms, more specifically the thorny issue of ‘updates’. The second half turned attention to the question of thresholds, with the aim of reducing the number of filings; this was a key trust objective, as the epigraph to this chapter attests.

The ’updating issue’ relates to the fact that SCFs are not one-off referrals. If the mother condition changes on subsequent midwife visits after the original filing, an ‘update’ must be filed. Although there had been general support for online submission in earlier meetings, the situation was not straightforward, as the need still existed for the electronic documents to be printed off and put securely in the notes. This caused obvious complications, potentially undermining the benefits of the online systems. The Head of Safeguarding described the two options for handling the updates in particular:

We’ve two options really. Option A, when the form is electronically updated the midwife prints them off and trots off to wherever the notes are in order to file them in the notes, or B, it’s up to the hospital midwives to check the file on every maternity service admission and print off the updates and file them in the notes.

To focus discussion, the Head of Safeguarding presented the following case scenario:

The community midwife sees a mother every week . . . the concerns relate to domestic violence. The initial special circumstances form is a low-level concern relating to partner’s controlling behaviour but the updates show rising levels of concern. What do you feel about that?

A brief discussion ensued summarised by the following salient points:

CM1:

I realise that she’s working in [X] and still has to make the journey but I would still go with A, that the person updating it should do it.

CM2:

I was just thinking that, with B, a labour ward midwife, she’s got a lot to do before she goes on the system to check everything, so it would be hard for her.

HS:

So you don’t want option B?

CM1 and CM2:

No . . .

HS:

No, we all agree with that.

HM:

No, that would not be secure, it would not be robust enough.

CM2:

The only thing they could do would be to ring the ward clerk, and get them to print off the update and put it in the notes.

HS:

And would that be acceptable?

CM2:

Yeah . . .

The Head of Safeguarding then presented a variation on the original scenario:

Let’s look at another scenario I dreamed up because women might not always come into maternity services when they are pregnant. It’s the same patient with a broken wrist after an accident that needs surgery, so she’s admitted to an orthopaedic ward. Admissions note the initial spec circ form [special circumstances form], and no questions are asked because it’s very low level. That’s the danger of relying on the hospital midwives to print off . . . you don’t see the creeping levels of concern. If they saw the updater, they might think of contacting children’s social care. What we don’t want to do is to introduce extra risk into a system and currently you would have all the updates in the patient notes – they open the notes and they can see the rising levels of concern.

In the ensuing discussion, the idea of an electronic alert on the patient administration system (PAS) was raised, which would draw attention to the submission of the updates. This took the conversation in an interesting direction:

HS:

The thing is, you could have an alert on PAS, it ticks the box to a certain extent but it’s still not as good as what they get now which is they open the notes and it’s there. And they won’t be able to access it because special circs forms can only be accessed by midwives, and they’d have to ring a midwife to print it off and put it in the notes.

SM:

But what’s the point of a spec circs form if other professionals can’t see it?

HS:

What are we saying that only midwives can look at special circs forms, why don’t we make them available to everybody? You could have your alert and if they want to have a look they could look. What did we make it that only midwives could look at it?

NN:

Because Information Governance were not happy about having so much confidential information on a shared drive, but we got passed that by saying only midwifery staff will have it.

HS:

But that’s nonsense. All the people who would have access to it have access to the patient’s notes . . . it’s only professionals. It’s dangerous to be honest with you. The shared drive, it’s not as if the public can see it and who would want to go and look at the midwifery notes anyway! I’ll have a word with Information Governance and override that . . . and then we could go for a failsafe couldn’t we. We’d have an alert on PAS just in case they’re not printed off and put in the notes. . .

The discussion concluded as follows:

HS:

At the last meeting, we had a lot of midwives saying get the hospital midwives to do it, but we have identified that is is probably building risk into the system. We’ve got a strong view that it’s safer for community midwives to do it themselves or we’ve got the option of ward clerks doing it. Could we agree that? I prefer the ward clerk one . . .

HM:

We’d have to make sure that the community midwife was always responsible for the filing, either they do it themselves or ensure that the ward clerk does.

HS:

To be absolutely clear, we ditch option B. We’ll include those two options then. Midwives will get that question then, that they have completed it . . . that is my input and I have made sure that it’s gone in the notes.

The second half of the meeting addressed the design of a traffic light system to attempt to standardise criteria for triggering SCFs. Again, the Head of Safeguarding led the discussion:

Does anyone think that the thresholds are right . . . this is a good time to look at this because we’re launching a new system. We’ve got so many flags on the system that it’s the cases with no flags that jump out. So if we want to change it. We need to define the criteria . . . we can do that now, it’s the best time.

Scenarios such as historic depression, raised in our contextual interviews with the senior midwives, featured in the ensuing discussion, the feeling being that such cases should not generate special circs forms, in and of themselves. SM offered the following hypothetical example of domestic violence:

SM:

Can I get your thoughts on a woman with previous DV [domestic violence]? The protocol says that we should get in touch and find out about the current partner.

HS:

That‘s not right, not if there are no new concerns. If she’s covered in bruises, that’s different.

SM:

The reason is because it shows they’re generally more vulnerable to any sort of abuse, that’s what we were told.

HS:

But that should be because she’s been specifically identified as a specially vulnerable person, not just because she’s had DV in the past. Lots of women would be mortified to think that . . . it has to be because she’s been identified as a specially vulnerable person. And you’d know why that was, for instance because she’s got learning disabilities. You need to use your professional judgement, not lists of criteria.

The debate continued, and is paraphrased below:

HM:

If she had previous depression and a teenage pregnancy, is that green or amber?

HS:

The thing is this is not the only piece of information; it’s in the notes that she’s had another baby and will include somewhere that she had postnatal depression. The purpose of special circumstances is not to give a potted history of everything that’s happened before; it’s to draw attention to something that’s extremely relevant to this pregnancy.

SM:

What would partner substance misuse come under? We get quite a few Asian women whose partners misuse, but they never do . . . would it be a green so we were aware of it?

HS:

It could be, but what is the impact . . . if it’s a big impact then it would be amber. . .

HM:

That’s the danger of lists . . .

HS:

As soon as you give lists, you close down professional judgement. What matters is whether in your judgement some extra intervention is needed. If you decide it’s something that you need to keep your eye on, just you, then it’s low level. If you need to keep your eye on it and maybe tell someone else, then it’s an orange . . . and if you think it needs a multiagency response potentially then higher. It’s defining your professional judgement not giving lists.

HM:

But there’s an anxiety when it comes to things like serious case reviews, that’s where the lists provide reassurance so it’s important how we word it . . .

HS:

We will need to provide some examples, but they should be examples not lists.

HM:

Yeah, that’s good way of approaching it.

HS:

And you can always make it an amber if you’re feeling nervous about it . . . and we can always review things down the line.