NHS England has announced the roll-out of an online system designed to identify patterns and trends in data routinely recorded in maternity services and send warning signals when a critical safety check is required.
At one of the pilot sites, Cathy Bevens, lead safety and governance midwife at Cambridge University Hospitals, commented: “We have had really positive experiences using the signal system – colleagues feel like we are being responsive. 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.”
The Maternity Outcomes Signal System (MOSS) is being introduced in response to the “Reading the Signals” report that followed an independent investigation into maternity and neonatal services in East Kent. According to NHS England, analysis demonstrated that it “would have detected signals in maternity units that later experienced serious incidents, including East Kent, Shrewsbury & Telford, Leeds, and Nottingham”.
Upon detecting a pattern or trend in data that indicates something unusual is happening, the MOSS system produces a warning signal, making it mandatory for maternity units to carry out a critical safety check within eight working days. Actions taken in line with these signals are also to be shared with regional and national teams.
Signals will be traffic light coded, with amber alerts reportedly linked to 95 percent confidence that “urgent attention” is required, and red alerts representing a 99 percent degree of confidence that this attention is needed. Data and signals will be visible at trust, ICB, regional, and national level, promoting transparency across the system and helping to ensure issues are dealt with quickly and efficiently.
Wes Streeting, secretary for health and social care, highlighted that “for too long, maternity warning signs have been missed”. Adding: “Now, this is a key step we are taking to improve maternity care. We have a sophisticated early warning system that will sound the alarm when patterns emerge that need urgent attention. Every signal will be visible from ward to boardroom, and every signal will be investigated.”
Wider trend: The role of digital in driving safer care
For a HTN Now discussion on building safer care and embedding clinical safety into digital pathways, we were joined by a panel including Corrina Hulkes, associate CNIO at Health Systems Support Ltd; Peter Hansell, CEO and co-founder at Isla Health; Victoria Mustafa, regional quality, safety and digital lead for London at NHS England; and Ruth North, clinical safety officer at Leicestershire Partnership NHS Trust. Panellists offered their insights on how digital pathways can be designed with safety at their core, exploring practical strategies, tools, and best practices for embedding clinical safety into digital care models to improve outcomes and build trust.
Barts Health has shared how a real-time data dashboard, linked to its EPR, has made an impact on patient safety, patient flow, and delivery of care. The M-BRACE project presents key information in a single place, including data relating to risk of falls, low blood sugar, and delays in assessment or transport, to support structured check-ins through the day. At 8-9am ward teams meet with support of the data, 10-12pm best practice reviews of every patient’s care take place, with check-ins 3-4pm, to review and track progress on discharges and identify any patients becoming unwell. The trust shared examples of how the number of patients receiving blood thinners (to prevent blood clots) doubled in one ward and how patients being ready for discharge increased.
