WAHT-OBS-104 It is the responsibility of every individual to check that this is the latest version/copy of this document.

GUIDELINE FOR THE SECURITY OF NEWBORN INFANTS This guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the parent/carer(s). Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION The newborn infant in hospital should be cared for in a secure environment to which access is restricted and a robust and reliable baby security system enforced. This, together with the strict criteria for the identification and labelling of the newborn infant, is essential to minimise both clinical and non-clinical risk issues for the most vulnerable of all patient groups. Please refer to related Policies/Guidelines:Maternity Department Escalation Policy: WAHT-CG-497 Policy to Identify All Patients :WAHT-CG-019 The patients covered by this guideline are newborn babies delivered in hospitals within Worcestershire Acute Hospitals NHS Trust including babies born at home but transferred into either the Alexandra or Worcestershire Royal Hospitals. THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS: Any staff member with direct responsibility for the welfare of newborn infants or working on a ward which cares for newborn infants. These may include midwives, neonatal nurses, nursery nurses, healthcare assistants, maternity support workers, ward clerks and paediatric doctors. Lead Clinician(s) Andrew Short Consultant Neonatologist Karen Kokoska Maternity Services Risk Manager Approved by Obstetric Clinical Governance/Risk Management Committee on:

3rd July 2015

This guideline should not be used after :

3rd July 2017

Date 14 June 2011 14 June 2011 18 August 2011 27 June 2011 22 August 2011 March 2015

July 2015

Key amendments to this guideline Amendment Exceptions to tagging on NICU 6.5 Inclusions for tagging on NICU 6.6 Location and number of cloaker devices This policy replaces Catalyst-File 11: Baby Tag Procedure V7 22.12.2004 Expiry date change – September 2014 Reviewed and updated relating to child health contact details and obtaining NHS number for abandoned baby & inclusion of Meadow Birth Centre. Monitoring tool included

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By: K Kokoska K Kokoska K Kokoska P Sleightholme K Kokoska K Kokoska

K Kokoska J Barratt

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GUIDELINE FOR THE SECURITY OF NEWBORN INFANTS CONTENTS

1. INTRODUCTION 1.1 Aim and scope of the guideline 1.2 Key staff groups

2. RESTRICTED ACCESS

3. EFFECTIVE SECURITY SYSTEM

4. IDENTIFICATION PROCEDURE FOR NEWBORN INFANTS

5. PROCESS FOR CHECKING THE CORRECT LABELLING OF NEWBORN INFANTS

6. USING THE SECURITY TAG SYSTEM (WRH only) 6.1 Registering the baby on the system and assigning a baby tag 6.2 Transferring security tagged newborn infants 6.3 Use of a cloaking device 6.4 Discharge of newborn infants 6.5 Exemptions for tagging on Meadow Birth Centre and NICU 6.6 Inclusion for tagging on NICU WRH

7. PROCEDURES FOR MANAGING BREACHES IN SECURITY 7.1 Discrepancies and/or failure in correct identification 7.2 Baby alarm activation – WRH only 7.3 Abandoned newborn infant 7.4 Abducted newborn infant

8. PROCESS FOR MONITORING COMPLIANCE WITH THIS GUIDELINE

9. APPENDICES 9.1 BABY TAG ALARM ACTIVATED RESPONSE PROCESS 9.2 ABANDONED BABY PROCESS 9.3 ABDUCTED BABY PROCESS

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1. INTRODUCTION 1.1 Aim and Scope of the Guideline The newborn in hospital should be cared for in a secure environment to which access is restricted and a robust and reliable baby security system enforced. This, together with the strict criteria for the identification and labelling of the newborn, is essential to minimise both clinical and non-clinical risk issues for the most vulnerable of all patient groups. Please refer to related Policies/Guidelines:Maternity Department Escalation Policy WAHT-CG-497 Policy to Identify All Patients WAHT–CG–019 The patients covered by this guideline are newborn babies delivered in hospitals within Worcestershire Acute Hospitals NHS Trust including babies born at home but transferred into either the Alexandra or Worcestershire Royal Hospitals. 1.2 Key Staff Groups This guideline is for use by the following staff groups: Any member of staff who has direct responsibility for the welfare of newborn infants or are working on a ward which cares for newborn infants. These may include midwives, neonatal nurses, nursery nurses, healthcare assistants, maternity support workers, ward clerks and paediatric doctors. 2. RESTRICTED ACCESS Staff identification cards are not issued until employees or prospective employees have been officially checked and authorised via the Criminal Records Bureau (CRB). A swipe card, which is part of staff identification, is required to enter the following areas where newborn infants are cared for. Restricted areas include:  Delivery Suite (both sites)  Postnatal Ward (both sites) – incorporating the Transitional Care Unit at WRH  Special Care Baby Unit – SCBU (Alexandra Hospital)  The neonatal corridor at WRH (linking Neonatal Intensive Care Unit to Delivery Suite)  Neonatal Intensive Care Unit NICU (WRH)  Meadow Birth Centre 3. EFFECTIVE SECURITY SYSTEM There are effective security and monitoring systems on both sites which are managed by security personnel. These include: 

24 hour CCTV (both sites)

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24 hour on-call security personnel (both sites)

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Newborn infant identification (both sites) and alarm tagging system (WRH only) – see sections 4, 5 and 6

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Clear communication and training to prevent ‘tailgating’ onto ward areas where newborn infants are cared for (both sites)

4. IDENTIFICATION PROCEDURE FOR NEWBORN INFANTS The following procedure is undertaken to ensure the timely and correct identification of the newborn infant whilst in hospital care (both sites): 

Following birth, each newborn infant has a unique hospital and NHS number generated via the K2 Guardian system. These numbers are clearly recorded on a minimum of two neonatal ankle-bands, which are applied to the newborn infant’s ankles, after confirming Guideline for the Security of Newborn Infants WAHT-OBS-104 Page 3 of 14

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that the newborn’s surname corresponds with his/her mothers. All labelled ankle-bands also record the date and time of birth 

For additional security, the numbers on the newborn’s ankle-bands are checked against those recorded on postpartum (purple) notes and neonatal record (white) to ensure they are correct. The numbers should be checked by staff involved in the transfer of care from Delivery Suite / Meadow Birth Centre to either Postnatal Ward / TCU (both sites), NICU (WRH) or the SCBU (Alexandra Hospital)

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All checking of newborn infant identification should occur in the presence of the baby’s parent(s)

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Simultaneously, an alarm tag should be allocated to the newborn infant via the electronic tag register (WRH only) – see section 6.1 Babies born within the Meadow Birth Centre are exempt from this process as they are expected to have an early discharge home. If for any reason a baby is transferred to NICU or postnatal ward then an electronic tag will be required for the durations of the baby’s admission.



Newborn infants should not be taken away from the place of birth (ordinarily the delivery room / Meadow Birth Centre or obstetric theatre) before the correct identification process has occurred and the labels and alarm tag (WRH) are applied to the newborn infant

5. PROCESS FOR CHECKING THE CORRECT LABELLING OF NEWBORN INFANTS Newborn Infants’ identification labels must be checked on a regular basis, including: 

On transfer from the place of delivery to another ward, such as from Delivery Suite / Meadow Birth Centre to the Postnatal Ward / TCU (both sites), NICU (WRH) and the SCBU (Alexandra Hospital). The check must be conducted in the presence of the parent(s) and details must correspond with those recorded in the notes

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Labels should be checked during the daily baby check by midwives, neonatal nurses and healthcare assistants and recorded in the postnatal (purple) notes or the neonatal notes if baby is on NICU / SCBU

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If an ankle-band has fallen off the newborn infant. it may only be reapplied once the information has been checked against the notes and verified by the baby’s mother with a midwife

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In the event that both identification labels are missing from a newborn, all babies within the ward / NICU / SCBU area must be checked to ensure they have the correct number of labels. The parents must confirm that the baby has not left the ward area.

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Procedures for resolving any discrepancies in newborn infant identification are outlined in section 7.1

6. USING THE SECURITY TAG SYSTEM (WRH only) 6.1 Registering the baby on the system and assigning a baby tag a. Collect the tag from the Baby Tag box located on the Midwives’ desk on Delivery Suite and register the newborn infant on the system b. Refer to the Launch pad Screen on PC (please do not close screens) c. If the screen is closed and or system failed: at first log on as User ID: BABY Password: TAG d. Operator Tab – displays 4 icons – we use only tabs 1 & 2 1. Card Holders 2. Monitor & Control 3. Reports 4. Local Printing e. Transaction monitor should be displayed continuously Guideline for the Security of Newborn Infants WAHT-OBS-104 Page 4 of 14

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f. If the above is NOT displayed Open Monitor & Control tab from launch pad g. Click on monitor tab (2) then transaction –screen is now displayed h. Take grey baby tag i. Present tag to tag reader (located next to PC) j. Desk top reader will display the Tags ID Number (remember number) k. Switch to card holder screen l. Click on binocular sign to search for tag Number Click on tag number to open tag number box m. Click Triangle symbol to edit /assign / remove baby’s details on chosen tag n. ONLY edit boxes containing Baby’s last name and first name please do not change other information fields o. Box – LAST NAME - Enter mother’s surname. NB if more than one patient with same surname i.e. smith please include mothers first name p. Box - First name - Baby’s name if known or “baby”. NB if multiple birth enter birth order i.e. Baby 1 or first name if known q. Tag default details will always show LAST name as tag number & FIRST name as baby r. s. t. u.

Confirm entered baby details are correct and click on the tick Switch to Monitor & Control window Re-present tag to tag reader and check new assigned details are correct Leave monitor/control screen open 5. NB Staff returning tags from ward areas to delivery suite MUST remove the discharged babies details (see 6.4)

6.2 Transferring security tagged newborn infants If the newborn infant is transferred to a secure and ‘restricted’ area (outlined in section 2), then the infant may be moved WITHOUT activating the alarm system or use of a cloaking device 6.3 Use of a cloaking device There are 2 cloaking devices located on inpatient ward for use by postnatal and TCU, and one located in NICU drug cupboard. When using the cloaking device place it as close to the electronic tag in a vertical position. When baby’s transfer is complete ensure the device is returned to its appropriate location. 6.4 Discharge of newborn infants On discharge, the security tag must be removed and recorded as such on the front cover of the postnatal notes. The security tag must be cleaned and returned to Delivery Suite. Tags must be ‘deactivated’ and returned to ‘default’ status, as follows: a) Tags returned to Delivery Suite daily MUST have assigned baby details removed to return the tag to default status – i.e. removal of the discharged baby’s details b) Open Monitor/control screen c) Present tag to tag reader (remember baby name) d) Switch to card holder screen e) Locate baby’s name from drop down box

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f) Click triangle to edit baby details to default status - i.e. Last name = tag number first name = baby g) Check tag details have returned to default status via reader on monitor/control screen 6.5 Exemptions for tagging Meadow Birth Centre Babies born within the Meadow Birth Centre are exempt from electronic tags as they are expected to have an early discharge home. If for any reason a baby is transferred to NICU or postnatal ward then an electronic tag will be required for the durations of the baby’s admission. Babies within the WRH NICU have additional security with double swipe access and robust entry and exit monitoring via video-cam and intercom. The following babies do not require routine tagging: 

Extreme premature infants

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Babies requiring intensive care

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Babies nursed in an incubator

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Babies transferred to NICU for resuscitation

When a baby is transferred to either postnatal or TCU an electronic tag MUST be attached before transfer from NICU. The correct checking procedure will take place on transfer from NICU staff to the ward staff. Any babies found not to have an electronic tag must be tagged as soon as possible. 6.6 Inclusion for tagging on NICU  Babies for transfer to postnatal ward / TCU 

Babies with complex safeguarding / social services concerns

7. PROCEDURES FOR MANAGING BREACHES IN SECURITY 7.1 Discrepancies and/or failure in correct identification In the event of the newborn infant’s identity band showing incorrect patient details the following action must be taken: 

Remove the incorrect ankle-band and retain for investigation

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Identify the newborn following the steps described in section 4 and apply a correct and verified identity band

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Check the newborn has not received incorrect drug/treatment

Complete a DatixWeb incident form and retain incorrect identity band (each patient misidentification must be investigated to determine the cause and reasonable action taken to reduce the likelihood of reoccurrence). It is imperative to correctly identify the newborn infant at each step in the care process. When an infant is found not to be wearing an identity band (on admission to the Postnatal Ward from Delivery Suite, for example), best practice identification is to use two elements:  Last name – Ask the parent(s) and cross reference with relevant clinical records  Date of birth – Ask the parent(s) and cross reference with relevant clinical records

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The Midwife should then follow sections 4 (for both sites) and 6 (WRH only) to correctly apply an identity band and security tag. The incident should be reported via DatixWeb. 7.2 Baby alarm activation – WRH only If a newborn infant is taken outside of the restricted areas whilst wearing a security tag, an alarm will activate. Is this still correct Staff on Delivery Suite and the Postnatal Ward must take the following actions: Delivery Suite responsibilities: 

The Delivery Suite Co-ordinator or nominated person must immediately check the monitor/screen on the Baby Alarm PC (located at the rear of the midwives’ station) to ascertain the following information: o Location of the alarm o Tag number o Baby’s details assigned to the alarmed tag

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A staff member must be immediately despatched to the location of the alarm to search for a possible newborn infant / relative or parent leaving ward area with woman’s possessions. (Tags may have fallen into baby clothes / laundry)

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A staff member must contact Postnatal Ward and NICU to inform staff regarding the location of the alarm and the baby’s details

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The Co-ordinator and person in charge of the ward / NICU must ensure a ‘lock-down’ of the following areas, delivery suite reception, NICU corridor and postnatal ward by despatching a member of staff (is available) to observe exits from the restricted access areas. This ‘lock down’ must be observed until either the newborn infant, the electronic tag is located or the activation is confirmed as a false alarm

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Security personnel are automatically alerted to the alarm and will attend the alarm location. They should also liaise with maternity staff in area of activation

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Staff must ensure the alarm is ‘stood down’ when it is safe to do so i.e. baby is found or security tag is located. (A common cause of false alarm is for the tag to be taken home in dirty baby clothes)

Postnatal Ward/NICU responsibilities: 

When the alarm activates, you should ensure a ‘lock-down’ of the ward area and despatch a member of staff (if available) to observe exits of the ward areas.

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On receipt of telephone call from Delivery Suite, ascertain the location of the alarm and the baby’s details assigned to the activated security tag

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Immediately check and confirm that baby is present on the ward/TCU / NICU. Check if the baby been taken for investigations to X-Ray or other areas within the hospital.

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If the baby is present, check for the location of the security tag o If no tag present, question whether a family member has recently left the ward and it is contained within their possession (i.e., within baby clothes) – the tag must be located

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If the baby is not present, has not been taken to X-Ray or other areas within the hospital and has not recently been discharged refer immediately to the ‘abducted baby’ procedure (section 7.4)

In all cases of an activated baby alarm, staff must make every reasonable attempt to locate the security tag.

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If a tag is not located please record this on the corresponding DatixWeb incident form relating to the electronic security alarm. Remember: there could be a possibility of more than one baby missing. If two babies are taken together, there may only be one alarm. Following alarm activation an incident form should be generated. With the exception of a false alarm, a ‘Root Cause Analysis’ (RCA) must be undertaken at the time of the event and documented on the investigation part of the incident form by the Delivery Suite co-ordinator. 7.3 Abandoned newborn infant On discovery or admission from an external agency of an abandoned baby, the staff member must notify the midwife / nurse in charge of the ward area in which the infant has been found or admitted. The midwife / Nurse should then escalate the information to the Delivery Suite Co-ordinator / person in charge of ward, who in turn will notify the Senior Midwife / Matron / Manager on Call / Consultant Paediatrician. In the event of an unexpected discovery of an abandoned baby ensure ‘lock-down’ of all ward areas with close liaison and cooperation of the security staff; check all mothers and babies to ensure they are all accounted for. Ensure there are no other cared for babies on the wards or within NICU (WRH) and SCBU (Alexandra) in the absence of the parent(s), e.g. awaiting adoption/fostering. Check that NICU/SCBU and the Children’s Wards can account for all of their babies. If still unable to locate the parent/carer(s) for the baby, confirm as ‘abandoned baby’. Inform the Matron / Divisional Director of Nursing &Midwifery and Directorate Manager who will escalate to the on call Duty Manager and Executive. The communications team should be informed to handle any prospective media enquiries. The police should be contacted promptly and an incident number obtained. Other groups/staff members that should be informed include Safeguarding lead, Social Services, the Supervisor of Midwives (who will notify the LSAMO) and community midwifery Team Leaders. The newborn infant should be cared for in the NICU (WRH) or SCBU (Alexandra) or children’s ward until alternative foster arrangements are made. The infant should be reviewed by a Paediatrician to ensure good health and determine his/her age. To obtain birth notification If no parental details are know inform Child Health within office hours 9-5 who will generate an NHS number (Tel 01905 – 681597 or 01562514591) Inform Child health of all known information i.e. DOB sex of baby etc Once an NHS number is generated obtain hospital number for baby. In the event the mother is found please inform Child Health to enable the birth details to be updated. Child Health will inform the following agencies.  Senior nursing / midwifery staff  Health Visitor  Registrar of Births, Marriages and Deaths  Childrens Services  Social Workers  General Practitioner  Police Guideline for the Security of Newborn Infants WAHT-OBS-104 Page 8 of 14

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Follow up arrangements for baby i.e. hearing / immunisation programs will be generated by Child Health.  . 7.4 Abducted newborn infant On discovering that a baby may have been abducted, the staff member must immediately inform the midwife / Nurse in charge of the ward area from which the infant has been taken. This midwife / Nurse should then escalate the information to the Delivery Suite / Ward Coordinator, who in turn will notify the Matron / Senior Midwife / Nurse Manager on call. When do the police get notified? Ensure ‘lock-down’ of all ward areas and check all mothers and babies to ensure they are all accounted for. Inform the following staff Police / safeguarding lead / Divisional Managers / Communication team to manage media / Supervisor of Midwives / Community Midwives / Child Health Department. 8. PROCESS FOR MONITORING COMPLIANCE WITH THIS GUIDELINE Monitoring compliance with this policy is undertaken via: 

Review of DatixWeb incidents



Ad hoc ‘baby-snatch’ alarm drills to identify strengths and weaknesses in the system

9. APPENDICES 9.1

Baby tag process

9.2

Abandoned Baby Flow Chart

9.3

Abducted Baby Flow Chart

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APPENDIX 9.1

BABY TAG ALARM ACTIVATED RESPONSE PROCESS Alarm sounds

Staff member on Delivery Suite to check monitor screen

Ascertain location baby name and tag number

Immediately inform PNW / NICU of the above information

Dispatch personnel from D/S/NICU /PNW to alarm location

Check if the named baby / tag is present

Is baby present YES Tag located

Baby discharged –Tag located

False Alarm confirmed - delivery suite coordinator stands down alarm

Tag not located / missing

Search of the area / laundry /baby cot

Baby missing

immediately activate Abducted Baby Process

Ask relatives to check at home / return tag as necessary

If tag missing after all reasonable actions taken Complete a DatixWeb incident form

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APPENDIX 9.2

ABANDONED BABY PROCESS NOTIFY NURSE / MIDWIFE IN CHARGE OF AREA

NOTIFY LABOUR WARD / WARD CO-ORDINATOR AND SENIOR NURSE / MIDWIFE /MATRON

Check all mothers and babies on wards are accounted for Ensure there are no other cared for babies on the Wards / NICU /SCBU In absence of parents E.g. awaiting adoption/fostering. Check NICU / SCBU /Children’s ward can account for all their babies

If confirmed – baby abandoned Immediately inform Security Department Inform Divisional Director of Nursing & Midwifery and Directorate Manager To Inform Duty Manager and Executive on call Inform Communications Department Inform Police / Obtain incident number 

Baby must be reviewed by Paediatrician to ensure good health and determine age.

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Baby must be cared for in Childrens Ward / Neonatal Unit/Special Care Baby Unit until alternative arrangements made.

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Childrens Services

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Inform Social Services – Duty on-call team out-of hours

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Notify Supervisor of Midwives who will inform the LSAMO

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Notify Community Midwifery Team Leaders

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Notify Safeguarding Lead Nurse

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Child Health

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APPENDIX 9.3

ABDUCTED BABY PROCESS The individual who discovers or suspects a baby has been abducted MUST IMMEDIATELY INFORM NURSE / MIDWIFE IN CHARGE OF WARD AREA AND SECURITY

WARD / LABOUR WARD COORDINATOR

INFORM SENIOR NURSE / MIDWIFE / MATRON / WARD STAFF Check all patients and babies are accounted for and Instigate an immediate search of the maternity unit / children’s ward

When baby abduction confirmed

Inform, Divisional Director of Nursing & Midwifery, Clinical Director and Divisional Managers / Matrons Inform Duty Manager / Executive on Call

Inform Police

Inform Communications Department 

Ensure ‘Lock- down’ of ward areas request security undertake a search and review of CCTV

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Nurse / Midwife to stay with family concerned and provide support

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Request visitors on ward to stay until Police have arrived for information to be obtained. If they have to leave ask if they are willing to provide name and address to Police

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Restrict visitors entering the ward unless it is a partner

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Explanation and support given to other families on ward

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Notify Supervisor of Midwives

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Obtain statements from all staff on duty

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Debrief to be arranged for all staff involved

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Ensure incident form completed and escalate as per trust policy

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WRH site only – review and audit of security tags

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Monitoring Tool Page/ Section of Key Document

Key control:

Checks to be carried out to confirm compliance with the policy:

How often the check will be carried out:

Responsible for carrying out the check:

Results of check reported to: (Responsible for also ensuring actions are developed to address any areas of non-compliance)

Frequency of reporting:

WHAT? The number of electronic Baby Tags available vs. the number on the System

HOW? Audit of the electronic system vs. number of baby alarm calls via switchboard.

WHEN? Every months

WHO? Audit midwife

WHERE? Maternity quality governance committee

WHEN? Twice year

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CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Karen Kokoska Karina Day Rachel Rees

Maternity Services Risk Manager / Midwife Audit/Training Midwife Audit/Training Midwife

Circulated to the following individuals for comments Name Designation Vicky Bullock

NICU Matron / Manager

Peter Sleightholme Phil Ridgway Jannine Dyke

Catalyst Manager ISS Lend Lease Facilities Management

Michael Diggens

Electrical Maintenance Manager-Facilities Management | Lend Lease Maternity guidelines documentation Judi Barratt / Rabia Imtiaz / Chris Mitchell group – MGDG Trudy Richardson Child Health Department

Circulated to the following CD’s/Heads of dept for comments from their directorates / departments Name Directorate / Department Dr Andrew Short Mr Angus Thomson Patti Paine Rachel Carter Alison Talbot Margaret Stewart

Clinical Director Paediatrics Clinical Director Obstetrics and Gynaecology Head of Midwifery Matron Inpatient Services , WRH Matron Inpatient Services , Alexandra Hospital Matron for Community Services / Senior Midwife

Circulated to the chair of the following committee’s / groups for comments Name Committee / group Judi Barratt

Maternity Guideline Documentation group

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