Clinical escalation is one of the most critical safeguards in healthcare but can also be one of the most vulnerable points of failure. In high-pressure environments, like maternity and neonatal settings, delays or breakdowns in escalating can mean that early warning signs are missed, concerns go unaddressed, or opportunities for timely innovation are lost.
Background
Chelsea and Westminster Hospital NHS Trust identified a need to improve clinical escalation in maternity and neonatal services. Staff feedback and incident reports showed that escalation was often inconsistent. Some staff felt unsure about when to escalate, others didn’t act on concerns, and some said they weren’t listened to when they did.
To address this, the Trust developed a Perinatal Escalation Toolkit. The aim was to remove barriers to escalation and improve patient safety through clearer processes and better staff support.
The project aimed to:
- Build staff confidence in raising concerns.
- Make escalation pathways clearer and more consistent.
- Improve responsiveness from senior clinical staff.
- Reduce incidents linked to poor escalation.
- Promote a culture of psychological safety and inclusive communication.
Ultimately, the goal was to ensure that all staff felt safe and supported when speaking up, leading to better care for patients.
Method
In June 2023, the Trust surveyed 120 clinical staff across maternity and neonatal services. Roles included midwives, nurses, nursery nurses, doctors in training, support workers, and students. The survey highlighted three key issues:
- uncertainty about when escalation is needed.
- hesitation to act on concerns.
- lack of response from those receiving escalations.
A multidisciplinary working group was formed. Using a Quality Improvement approach and Plan-Do-Study-Act cycles, the team developed and tested practical tools:
- role-specific lanyards to identify escalation contacts.
- pocket-sized reference cards with communication tools like SBAR, AID, and Teach or Treat
- QR-coded posters linking to site-specific escalation flowcharts.
These tools were co-designed with frontline staff to ensure they were relevant and easy to use.
The toolkit was launched Trust-wide through newsletters, posters, and daily ward rounds led by MDT leaders. A parallel campaign promoted psychological safety, kindness, and inclusivity.
Results
Three months after launch, a follow-up survey showed:
- The percentage of staff who always felt able to escalate increased from 81% to 83%.
- Improved staff confidence when and how to escalate concerns.
- Increased awareness and use of the toolkit.
- 86% of respondents reporting SBAR use
- 52% of respondents reporting AIM use
- Positive feedback on the accessibility and usefulness of the tools.
“The lanyards make it easier to know who is who. This is especially useful in emergency situations. Teach or Treat and PITSTOP is particularly useful on labour ward.”
Next steps
The project will continue to grow through ongoing feedback and iterative refinement.
Local plans include:
- continued staff engagement to reinforce toolkit use.
- development of new resources based on staff feedback
- ongoing staff training to support escalation and psychological safety
- quarterly evaluations will monitor progress.
- annual reviews of escalation related incidents will guide further improvements.
The Trust is also working with Imperial College Health Partners to expand the toolkit across North West London, and share their learnings with all Maternity units nationally.
Partners
Chelsea and Westminster Hospital NHS Trust, NHS England
Find out more
Get in touch with Matthew Wyatt, Senior Innovation Manager, at Matthew.Wyatt@imperialcollegehealthpartners.com
