by Vivien Mortimore, Michelle Richardson & Sally Unwin

Poster Download

Background & Problem:

The number of Gloucestershire infants experiencing serious non-accidental injury is twice national incidence. ACEs were previously not discussed at booking. No published maternity projects exist.

SMART Aim:

Use ACEs toolkit at booking with 100% of women/partners using maternity services in a pilot area by July 2019. Assessment of existing risk/protective factors in 100% of cases where ACEs identified and evidence of a personalised plan in maternal notes.

Method:

A toolkit was developed and piloted. Feedback was obtained from professionals and women/partners.

Results:

Of 44 families 10 had ACEs:

  • 1 referred through safeguarding processes
  • 4 offered Early Help
  • 5 had existing protective factors.

10 families provided feedback. All recognised the need for ACEs conversation and found the questions acceptable. Midwives requested information on improving their response to ACEs identified. Health visitors welcomed the project.

Lessons Learnt:

  • Clarity around information governance
  • Strengthen staff education
  • Importance of revisiting the ACEs questions
  • Further consideration of domestic abuse
  • The need for support for professionals with experience of ACEs
  • Refining toolkit
  • Strengthen the response
  • Publish findings
  • Further implementation
Quality Improvement Presenter(s)
Vivien Mortimore – Divisional Director of Quality and Nursing and Chief Midwife
Trust Named Nurse/Midwife Safeguarding Children
Michelle Richardson – Senior Sister, Neonatal Unit
Sally Unwin – Specialist Midwife Safeguarding Children and Vulnerable Women
Quality Improvement Team
Dee Gibson-Wain, Trust Associate Director Education and Development
Community Midwives Quedgeley and Kingsway (pilot area).
Gloucestershire Action on ACEs Panel.