GHFT - Identifying ACEs in families who use maternity and neonatal services to improve the response to risk and build resilience to strengthen parenting capacity.

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.


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.


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


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

Next steps:

• Refining toolkit

• Strengthen the response

• Publish findings

• Further implementation



  • Acute
  • Acute > Family Care
  • Acute > Family Care > Maternity
  • Leadership and Management
  • Leadership and Management > Quality and Performance
  • Leadership and Management > Quality and Performance > QI
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