The document discusses the importance of collaboration, openness and transparency in maternity services. It shares the author's personal experience of losing her son Hugo after he was born extremely prematurely at 24 weeks due to HELLP syndrome. The author has since worked to improve bereavement information and ensure bereaved families are included in surveys of maternity and neonatal services. It stresses the need to include all voices, especially those seldom heard.

1. Why a culture of collaboration,
openness, and transparency is essential
for a successful maternity service
Leigh Kendall FRSA
@leighakendall
@leighakendall #HSJpatientsafety

2. Hugo
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3. • HELLP syndrome at 24 weeks’
pregnant (rare, life-threatening
pregnancy complication – can cause
multiple organ failure unless baby is
born).
• My son Hugo weighed just 420
grams (about the same size as
a tin of baked beans)
• Hugo lived for 35 days.
• He was too small, and
premature. His treatment was
withdrawn.
@leighakendall #HSJpatientsafety

4. @leighakendall #HSJpatientsafety

5. Improving bereavement
information
@leighakendall #HSJpatientsafety

6. • Co-produced bid
to NHS England
Maternity
Challenge Fund
• Workshops at
Kingston and St
George’s
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7. @leighakendall #HSJpatientsafety

8. • Bereaved families are excluded from the
neonatal and maternity CQC surveys
• Attitudes are changing – National
Bereavement Pathway and new guidelines
released 2017.
@leighakendall #HSJpatientsafety

9. • I am white, middle class, and articulate (I
speak fluent NHS!)
• Even so, I have had to fight to get my voice
heard.
• Let’s make sure we include those seldom-
heard voices too.
@leighakendall #HSJpatientsafety