Guidance

Learning from screening incidents

Published 21 June 2021

Applies to England

1. Failsafe in screening programmes

When things don’t go as planned, failsafe processes help to identify these in real time so that action can be taken before harm occurs. Here’s an example.

Mrs. Russell books for maternity care and accepts the offer of the 20 week screening scan. Mrs. Russell does not attend this scan appointment.

Do you have processes in place to follow up women who do not attend screening appointments?

Mrs. Russell’s next antenatal appointment was at 24 weeks. If you waited to follow her non-attendance at this appointment, she would be outside the gestational screening window (that is after 23 weeks).

We have evidence from screening safety incidents that some providers do not have processes in place for following up non-attendance at screening appointments. They therefore do not find out if:

• the screening appointment was never received
• the purpose of the screening appointment was understood for example was there a language barrier
• the woman understood there were specific time frames to undertake the test

Sometimes these ‘missed screening’ appointments are undetected until reporting on key performance indicators 3 months later.

For failsafe processes to be effective, they must be timely.

2. Learning scenarios

We provide the following real scenarios to demonstrate situations where the screening pathway was not delivered as specified. We hope that you will be able to use these scenarios to look at your local pathway and confirm you have failsafe processes or to address any gaps that may exist.

2.1 20-week screening scan not completed within timescales

Example 1

A maternity service submitting key performance data found that scans were not always completed at the right time. They were not aware that this was happening until they started collecting data for the KPI. When they looked at their data they found:

• 4 women did not have a completed screening scan recorded
• 2 women had screening scan appointments incorrectly cancelled or rescheduled and were completed outside of required timescales
• 2 women were not given a screening scan appointment following their dating scan
• 61 women received initial screening scan after 20⁺⁶ weeks without a documented reason for this
• 15 women required a repeat USS appointment to complete the screening scan and this was scheduled after 23⁺⁰ weeks without a documented reason for this

Example 2

Four women did not attend their 20-week screening scan. These women were not followed up, they were between 24 and 30 weeks pregnant when discovered.