Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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158 12 Deaths from psychiatric causes Table 12.3 Main psychiatric diagnosis by cause of death; United Kingdom: 2003-05. Diagnosis Suicide Substance misuse Cause of death Physical illness Violence Psychosis 5 0 0 0 5 Severe depressive illness 7 0 2 0 9 Anxiety/depressive adjustment 3 0 2 1 6 Alcohol dependent 1 1 8 2 12 Drug dependent 5 20 15 5 45 Personality disorder 2 0 2 0 4 Learning disability 0 0 2 0 2 No psychiatric diagnosis 0 1 1 0 2 Unascertained 10 0 1 2 13 All 33 22 33 10 98 Suicide Five women who were suffering from a psychotic illness committed suicide. One death occurred in late pregnancy and another shortly after delivery. Both of these women had a previous history of postpartum psychosis and bipolar illness. The three other women died later after childbirth, one of whom had a previous history of puerperal psychosis. There were no cases of psychosis in the other causes of psychiatric death. Seven women who committed suicide were suffering from a severe depressive illness. One died in midpregnancy and the others later after childbirth. Four of these women had a previous history of severe depression. In addition, two women who died from medical conditions were suffering from a severe depressive illness: one died in early pregnancy from myocarditis and a second a few weeks after delivery from adult respiratory distress syndrome. In both cases it was felt that the women’s mental health had delayed their access to medical care and that the antidepressants they were receiving had contributed to their condition. Substance misuse Substance misuse was either directly or indirectly associated with the deaths of 57 women. Twelve of these women were alcohol dependent and forty-fi ve were illicit drug dependent. Most of the drug dependent women were using heroin, but a large number were also misusing amphetamines, cocaine, benzodiazepines and alcohol. Six of the women who died from suicide were known substance misusers, fi ve of whom used intravenous heroin. Four died by hanging and two died from an overdose of paracetamol, one in pregnancy and one later after delivery. Twenty two substance misusing women died after a drug overdose, one of which was due to alcohol toxicity. Eight more women who were alcohol dependent and a further fi fteen who were drug dependent died from medical causes directly or indirectly associated with their substance misuse. A further two alcohol dependent women died in house fi res while intoxicated and fi ve drug dependent women were either murdered or died in a road traffi c accident as a consequence of their drug use. All
Current psychiatric treatment In the last two Reports the majority of women whose deaths were due to, or associated with, psychiatric causes were receiving some form of treatment for a psychiatric disorder during their maternity and over half of them were in contact with psychiatric services. Table 12.4 shows the highest level of psychiatric care provided for these women this triennium. Table 12.4 Highest level of psychiatric care during index pregnancy: United Kingdom 2003-05. Level of care Suicide Substance misuse Cause of death Physical illness Violence Mother and baby unit 1 0 0 0 1 Inpatient general 1 0 2 0 3 Perinatal psychiatric team 1 0 0 0 1 General psychiatric team 4 1 5 0 10 Drug and alcohol team 0 8 9 2 19 GP only 14 7 4 3 28 None 8 5 9 4 26 Not known 4 1 4 1 10 All 33 22 33 10 98 As in the previous Report the majority, 62 (63%), of women who died were receiving some type of psychiatric treatment. However, the number admitted to a psychiatric inpatient unit has fallen. Only four women this triennium were receiving inpatient care compared to ten in preceding Report, and, as last time, only one woman was treated in a specialist mother and baby unit. Twenty-eight women received no treatment for their psychiatric disorder and in ten cases no details were available. Less than half of the women who had substance misuse problems had been in contact with specialist drug or alcohol services during their pregnancy. Risk identifi cation and management As shown in Table 12.5, 79 of the 98 women whose deaths are considered in this Chapter had a past psychiatric history and were at risk of a recurrence of their disorder, or a relapse of their condition, following childbirth. For 55 (70%) of these women this risk was identifi ed in early pregnancy but less than half of these women had had a management plan developed and put in place. In only a few of these cases was the management plan either adequate or communicated between maternity and psychiatric services. All 159
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
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Contents Maternal deaths Indirectly
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Foreword Having a baby is a joyous
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The ‘top ten’ key recommendatio
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Migrant women 4. All pregnant mothe
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Clinical skills 7. Maternity servic
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Early warning scoring system 9. The
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References 1 Redshaw M, Rowe R, Hoc
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Working together to save mothers’
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Severe maternal morbidity, “near
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At a national level In every countr
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Table 1 Defi nitions of maternal de
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For the past nine years, ONS have b
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Chapter 1 Which mothers died, and w
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Key fi ndings for 2003-05 Maternal
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Figure 1.1: Overall maternal mortal
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Coincidental deaths The deaths of 5
Page 37 and 38:
Leading causes of maternal deaths:
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Table 1.5 Maternal deaths by gestat
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Table 1.7 Number of maternal deaths
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of note is that every women who die
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Table 1.11 Numbers and percentage o
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These messages are repeated in many
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Doctors may need specifi c training
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Table 1.13 Total number of Direct a
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Ovarian hyperstimulation syndrome (
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The obese women who died From the n
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Pre-pregnancy counselling and weigh
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Table 1.19 Direct and Indirect mate
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double the number of cases in the l
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was ill and he should take her to a
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Table 1.22 Characteristics of the a
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Page 69 and 70:
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Most staff reported learning clinic
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exception. The health service has a
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17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
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Table A1.4 Direct and Indirect deat
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Body mass index varies with age, be
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2 Thrombosis and thromboembolism Ja
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Pulmonary embolism Of the 33 women
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Family history In two deaths there
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vigilance and take symptoms serious
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Deaths after caesarean section Seve
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of pregnancy, seven had identifi ab
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Annex 2.1 Summary of the key recomm
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The grades of recommendations (B or
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High risk patients Patients assesse
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Table 3.2 Numbers of deaths from pr
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publication from the United States
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References 1 Knight M, Kurinczuk JJ
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obstetricians and anaesthetists rou
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Detailed guidelines for the managem
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acute bleeding situation although i
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References 1 Brace V, Penney G, Hal
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Table 5.1 Direct deaths attributed
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of over ten litres. Despite a hyste
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References 1 Clark SL, Pavlova Z, G
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The women who died The ages of the
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A woman who had not been long in th
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7 Genital tract sepsis Ann Harper G
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Sepsis in early pregnancy Six women
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Box 7.3 Learning points: Sepsis in
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Risk factors for, and the identifi
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Box 7.7 Features of septicaemic sho
Page 135 and 136: 8 Anaesthesia Griselda Cooper and J
Page 137 and 138: The third case also highlights the
Page 139 and 140: A woman suffered a concealed haemor
Page 141 and 142: Sepsis Poor anaesthetic or resuscit
Page 143 and 144: What did you learn from this case a
Page 145 and 146: 9 Cardiac disease Catherine Nelson-
Page 147 and 148: Table 9.2 Causes of maternal death
Page 149 and 150: an estimated incidence of 1.1 per 1
Page 151 and 152: Quality of care Care was considered
Page 153 and 154: y a doctor, with a systolic blood p
Page 155 and 156: Box 9.3 Learning points: peripartum
Page 157 and 158: Infectious endocarditis Two women d
Page 159 and 160: 10 Other Indirect deaths Michael de
Page 161 and 162: Table 10.1 Causes of Other Indirect
Page 163 and 164: Fifty-eight of the eighty-seven wom
Page 165 and 166: Previous Reports have emphasised th
Page 167 and 168: Aspergillosis usually occurs in imm
Page 169 and 170: Liver disease There were four mater
Page 171 and 172: Diseases of the circulatory system
Page 173 and 174: 11 Cancer and other tumours Gwyneth
Page 175 and 176: her delivery, but her case should h
Page 177 and 178: Severe abdominal and back pain, sci
Page 179 and 180: References 1 Drife, J O. The contri
Page 181 and 182: Psychiatric deaths: Specifi c recom
Page 183 and 184: cut off point for maternal deaths,
Page 185: Report, 26 deaths from suicide were
Page 189 and 190: 12 Deaths from psychiatric causes S
Page 191 and 192: caring for the woman. Nonetheless,
Page 193 and 194: Commentary on deaths related to dru
Page 195 and 196: It is known that women presenting w
Page 197 and 198: antibiotics nor returned to her gen
Page 199 and 200: It is still evident that there is a
Page 201 and 202: 13 Domestic abuse Gwyneth Lewis Dom
Page 203 and 204: The mothers affected: 2003-05 Durin
Page 205 and 206: Of the women who were murdered: •
Page 207 and 208: Annex 13.1 The recommendations of t
Page 209 and 210: Road traffi c accidents during and
Page 211 and 212: Table 14.2 Late deaths known, or no
Page 213 and 214: Table 15.2 Quality of autopsy repor
Page 215 and 216: Haemorrhage Thirteen of the sevente
Page 217 and 218: association with obesity as eight o
Page 219 and 220: Obesity was present in 55% of these
Page 221 and 222: Toxicology showed non-lethal citalo
Page 223 and 224: Box 15.6 Pathology learning points:
Page 225 and 226: References 1 Royal College of Patho
Page 227 and 228: 16 Issues for midwives Grace Edward
Page 229 and 230: effective service for women who may
Page 231 and 232: Professional accountability and com
Page 233 and 234: Box 16.1 Key physical signs that ma
Page 235 and 236: Midwives’ responsibility for vuln
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Table 16.1 Poor or non attenders fo
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Action checklist for midwifery prac
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17 Issues for General Practitioners
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Box 17.1 Summary of the key issues
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Box 17.3 Risk factors for venous th
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headaches. The indications for emer
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Box 17.8 GP learning points: Heartb
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medication after delivery and been
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Women with mitral stenosis may seem
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signifi cance in the pregnancy. It
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References 1 RCOG. Thromboprophylax
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Introduction For the fi rst time in
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measures were of a good or excellen
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A woman collapsed at home following
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never preclude requesting opinion f
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admissions represented 0.9% of all
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Modifi ed early warning scoring sys
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Box 19.3 Critical care learning poi
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her initial collapse she was transf
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Chapter 19 Annex A This Annex is av
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Table 20.1 Inclusion criteria used
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Table 20.3 Numbers and rates of sev
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References 1 Baskett TF,.O’Connel
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The Director of the Maternal Death
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Verifi cation of Ascertainment Asce
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Scotland A single panel of assessor
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CEMACH Regional Managers East of En
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Regional Assessors in Pathology Eas
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NORTHERN IRELAND Department of Heal
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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