Guidance

Newborn and infant physical examination screening: learning from incidents

Published 21 June 2021

Applies to England

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. Let’s look at the example below:

Baby Russell was born at 38 weeks gestation and was a breech birth. He was discharged home at 48 hours of age without a NIPE newborn examination being done. The community midwife visited on day 3, but did not check that the NIPE newborn examination had been completed.

Are you checking that all NIPE newborn examinations for babies in your care are completed within 72 hours birth?

All babies should have their NIPE newborn examination completed before 72 hours of age. This should include babies within the neonatal unit (who are not too ill or too young for NIPE newborn screening) and those in different settings where responsibility for completion of NIPE has not been formally transferred on the national NIPE IT system, SMaRT4NIPE (S4N).

Do you communicate with the relevant services that a baby still needs a NIPE if they are discharged home before the NIPE is completed?

Do you have a process to follow up babies transferred from or into your care from another maternity service who have not been offered a NIPE newborn examination?

Baby Russell was seen by 3 different community midwives on days 3, 5 and 10, and no one had identified that a NIPE newborn examination had not been completed. He was later examined by the GP for the 6 to 8 week examination and was found to have a dislocated hip. If the NIPE examination had been completed in line with national guidance, this would have minimised a potential delay in treatment for baby Russell. For example, a hip ultrasound scan could have been undertaken at 4 weeks of age with an assessment by an orthopaedic specialist by 6 weeks of age.

All healthcare professionals caring for baby Russell have a responsibility to check the NIPE screening status at each contact. There also needs to be a systematic and independent check of screening status for all newborn babies on the national NIPE IT system to identify babies who may have missed screening in time for corrective action.

We know screening safety incidents reported, that some providers are not checking the status of babies along the screening pathways. This means that babies without a completed NIPE screening pathway may be missed or only identified when reporting on key performance indicators.

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

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 that you have failsafe processes or to address any gaps that may exist.

1. Delayed screening

On day 5, the midwife realised that NIPE was not offered or undertaken within the national standard timeframe of within 72 hours of birth. It was then completed and comments added regarding the reason for the delay. This breach of standard will be evidenced when the key performance indicators for NP1 are submitted. Regular use of nationally provided data reports and monitoring of coverage (by 72 hours) provides an opportunity to review all breaches in performance targets and address local process issues.

2. Incomplete screening

An audit of the neonatal intensive care unit identified that a baby who was discharged home had received incomplete screening. The eyes had not been examined before discharge. In babies who are too ill for screening, all elements of the examination should be completed as soon as the baby’s condition allows. Babies that are too young for the NIPE newborn examination should have it completed when they reach 34 weeks corrected age and before they are discharged. Responsibility for the tracking of completion of the screening pathway remains with the maternity unit of birth unless the record is transferred on S4N. This includes babies on neonatal intensive care and in other paediatric inpatient settings.

3. Missed screening

A baby was born over a bank holiday weekend and discharged home at 6 hours of age. The NIPE newborn examination was not completed prior to discharge and arrangements were not put in place for the baby to return to the trust NIPE clinic or have the screen in the community setting. This was only identified when the maternity unit reported their quarterly key performance indicator for NP1 and the baby’s S4N record showed that screening had not taken place.

Babies should be offered NIPE newborn screening prior to discharge and the examination should be recorded onto the national IT system for NIPE. There is web access to S4N at bank holidays and weekends and all screening results should be entered as soon as possible. If a baby has not been screened this should be highlighted in discharge documentation and arrangements need to be put in place for it to be completed. If the maternity service had been checking S4N regularly the missed screen would have been identified earlier rather than months later when the KPI was reported.

4. Missed risk factors for developmental dysplasia of the hip

A baby presents aged 12 months with a dislocated hip requiring a surgical procedure. The screening history is reviewed and identifies the baby was a breech presentation at 36 weeks but following external cephalic version had a normal vaginal delivery. The history of breech presentation at 36 weeks gestation was missed at the NIPE newborn examination and was not included in the discharge notification. This means that the need to refer the baby for a hip ultrasound scan because of presence of a national hip risk factor was missed.

If this had been identified at either the newborn examination or the subsequent 6 to 8 week check with the GP then the baby would have referred for an earlier hip ultrasound and orthopaedic review which may have prevented the need for surgery. Review of maternal case notes, discussion with parents and documentation of NIPE national hip risk factors needs to be accurate. Inclusion within discharge notification can support identification of babies that have missed referral for onward investigation of conditions identified within the NIPE newborn screen.

5. Delayed pathway for developmental dysplasia of the hip (DDH)

The NIPE newborn examination identified a suspected dislocated hip (screen positive for DDH) 48 hours after birth. The NIPE practitioner made an electronic referral for a hip ultrasound scan. This was not received so an appointment was not issued. No process was in place to check the hip ultrasound scan outcome which meant that the gap in the referral process was not identified. This was only identified when the GP completed the 6 to 8 week NIPE infant examination. If the maternity unit had checked that the referral had been made, an appointment issued and the outcome of the scan recorded on S4N the baby would have had earlier hip ultrasound scan and orthopaedic specialist review.

6. Audit of the NIPE failsafe pathway

In addition to keeping S4N up to date and reviewing the nationally provided reports you can also check your failsafe processes by running local data reports and by audit. Example of audits that you can complete include checking:

• timeliness of communication pathways when a baby dies
• that all screen positive referrals have completed within the recommended timeframes and recorded on S4N
• that all outcomes are recorded on S4N
• that consent or decline of NIPE screening is recorded
• that screening information has been provided
• that screening results are discussed and that this is documented
• babies that ‘did not attend’ or ‘were not brought’, focusing on health inequalities and checking that your services are meeting the needs of protected groups