All newborn babies are offered blood spot screening to test for 9 rare but serious conditions. Blood samples are taken from a baby's heel and sent to a laboratory for testing.
Samples should be received within 3 days of being taken and any that are delayed by more than 14 days cannot be tested. Affected babies can suffer serious harm if they do not receive treatment as soon as possible.
Delays last year
In the run up to Christmas last year one regional screening laboratory noticed they were receiving less samples than they were expecting. The newborn blood spot failsafe solution (NBSFS) IT system showed a delay in samples arriving from several maternity units in the area.
Following this, Public Health England's screening quality assurance service (SQAS) team and screening commissioners were notified and a screening incident was declared.
Trusts in the affected area and the laboratory immediately set about finding out how many samples were missing and it quickly became obvious that there had been a postage delay which affected several hundred samples.
Because of this prompt team working, action was taken as quickly as possible to retest babies whose samples were delayed.
Community midwifery staff worked very hard to revisit families whose sample had not arrived to explain what had happened and re-offer the test. Maternity services put in place alternative delivery methods for these new samples and monitored the situation closely.
The affected laboratory extended their hours and managed to get all the samples tested and thankfully no child was harmed as a result of the delays.
Prevention
A number of steps have been taken to avoid a similar situation arising again this year, including:
- asking trusts to consider alternative arrangements over extended bank holidays, such as Christmas, or when bad weather is likely to cause postal delays
- requesting maternity services continue using the newborn failsafe solution but check that alternative arrangements are working
- encouraging all laboratories to monitor the number of samples they get every day so things can quickly be escalated if the expected number do not arrive
Longer term plans include Royal Mail training their staff to spot the envelopes used to post blood spot samples so they can deliver them quicker.
Work is ongoing to redesign the envelopes to make them even easier to spot for Royal Mail staff. We don't have a definitive start date as yet for the new envelopes, but we will keep you updated via the blog.
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