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

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254 APPENDIX 1: Method of Enquiry Naufi l Alam The Confi dential Enquiry into Maternal and Child Health (CEMACH) has fi ve regional offi ces in England and works with partner offi ces in Wales, Northern Ireland and Scotland. The work is co-ordinated by a Central Offi ce in London. Each of the regional offi ces has contacts within every Trust that provides maternity care, at the Maternity-Unit level. The Enquiry has its own Board with representation from the Royal College of Obstetricians and Gynaecologists (which hosts the Enquiry), Royal College of Midwives, Royal College of Pathologists, Faculty of Public Health, Royal College of Paediatrics and Child Health, and the Royal College of Anaesthetists. Recent additions to the board include the Royal College of General Practitioners and the Royal College of Psychiatrists. From 2003 to 2005, CEMACH was commissioned by the National Institute for Clinical Excellence (NICE) to conduct the Maternal Death Enquiry (MDE) in England and Wales. Since 2005, this commissioning role has been carried out by the National Patient Safety Agency (NPSA). In Northern Ireland CEMACH is commissioned by the Northern Ireland Department of Health, which contributes funds for their participation in the Enquiry. In Scotland, the Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH), acting on behalf of NHS Quality Improvement Scotland (NHSQIS) conducts its own Enquiry programme, but cases are forwarded to the Enquiry’s central assessors and included in the triennial Report. England and Wales It is a government requirement that all maternal deaths should be subject to this Confi dential Enquiry, and all health professionals have a duty to provide the information required. In participating in the Confi dential Enquiry, the professionals concerned are asked for three things: (i) to provide a full and accurate account of the circumstances leading to the woman’s death, with supporting records (ii) to refl ect on any clinical or other lessons that have been learned, either personally or as part of the wider context The responsibility for initiating an enquiry into maternal death lies with the CEMACH Regional Manager (RM). Following a pregnancy-associated-maternal-death, a notifi cation is usually made by one of the health professionals involved in the care of the woman to the relevant CEMACH RM. Cases are also reported by the coroners, Local Supervising Authority Midwifery Offi cers (LSAMO), and others. Data are also cross validated with data received from the Offi ce for National Statistics (ONS). The data received from ONS are discussed more fully below (see “Verifi cation of Ascertainment”). The enquiry is initiated using a standard data collection form (Maternal Enquiry pro forma; MDR-1) which is completed by obstetricians, anaesthetists, pathologists, general practitioners, midwives and any other professionals that were involved in the care of the woman. Copies of case notes are obtained, where relevant, and in some cases additional written statements are supplied. Each case is then prepared for a two stage review and assessment process, the fi rst occurring at a regional level, and the second occurring at a central level. Following collection of all the relevant information, the records are anonymised and circulated by the CEMACH Regional Manager to Regional Assessors (RA). The obstetric and midwifery assessors review all cases. Anaesthetic assessors review all cases where there was involvement of an anaesthetic or intensive care. Every possible attempt is made to obtain full details of any autopsy and pathological investigations, and these are reviewed by the pathology assessor. The assessors add their comments and opinions regarding the cause or causes of death, before returning the completed form to the relevant Regional Offi ce where core notifi cation data are entered onto a database.
The Director of the Maternal Death Enquiry then reviews all cases and allocates the cases for further assessment as necessary. There are a number of central assessors in different specialities, e.g. cardiac disease, psychiatric illness etc. or clinical practice, e.g. midwifery, general practice etc. The Director will make a decision as to which is the most appropriate central assessor to review each case, although a case may be sent to more than one assessor. The Director then works in collaboration with the central assessors to review all available recorded facts about each case, and assess the factors that may have led to death. All details regarding the death, including the agreed clinical cause-of-death are recorded in a database. All data and databases are held in accordance with CEMACH’s information security procedures. This ensures anonymity at different stages of the Enquiry process, guarantees confi dentiality, and safeguards any identifi able information for the duration it is held. After preparation of the Report, and before its publication, all maternal death report forms, related documents and fi les relating to the period of the Report are destroyed, and all electronic data are irreversibly anonymised. 255
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
Page 5 and 6:
Contents Maternal deaths Indirectly
Page 7 and 8:
Foreword Having a baby is a joyous
Page 9 and 10:
The ‘top ten’ key recommendatio
Page 11 and 12:
Migrant women 4. All pregnant mothe
Page 13 and 14:
Clinical skills 7. Maternity servic
Page 15 and 16:
Early warning scoring system 9. The
Page 17 and 18:
References 1 Redshaw M, Rowe R, Hoc
Page 19 and 20:
Working together to save mothers’
Page 21 and 22:
Severe maternal morbidity, “near
Page 23 and 24:
At a national level In every countr
Page 25 and 26:
Table 1 Defi nitions of maternal de
Page 27 and 28:
For the past nine years, ONS have b
Page 29 and 30:
Chapter 1 Which mothers died, and w
Page 31 and 32:
Key fi ndings for 2003-05 Maternal
Page 33 and 34:
Figure 1.1: Overall maternal mortal
Page 35 and 36:
Coincidental deaths The deaths of 5
Page 37 and 38:
Leading causes of maternal deaths:
Page 39 and 40:
Table 1.5 Maternal deaths by gestat
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Table 1.7 Number of maternal deaths
Page 43 and 44:
of note is that every women who die
Page 45 and 46:
Table 1.11 Numbers and percentage o
Page 47 and 48:
These messages are repeated in many
Page 49 and 50:
Doctors may need specifi c training
Page 51 and 52:
Table 1.13 Total number of Direct a
Page 53 and 54:
Ovarian hyperstimulation syndrome (
Page 55 and 56:
The obese women who died From the n
Page 57 and 58:
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
Page 63 and 64:
was ill and he should take her to a
Page 65 and 66:
Table 1.22 Characteristics of the a
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Most staff reported learning clinic
Page 73 and 74:
exception. The health service has a
Page 75 and 76:
17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
Page 79 and 80:
Table A1.4 Direct and Indirect deat
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Body mass index varies with age, be
Page 83 and 84:
2 Thrombosis and thromboembolism Ja
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Pulmonary embolism Of the 33 women
Page 87 and 88:
Family history In two deaths there
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vigilance and take symptoms serious
Page 91 and 92:
Deaths after caesarean section Seve
Page 93 and 94:
of pregnancy, seven had identifi ab
Page 95 and 96:
Annex 2.1 Summary of the key recomm
Page 97 and 98:
The grades of recommendations (B or
Page 99 and 100:
High risk patients Patients assesse
Page 101 and 102:
Table 3.2 Numbers of deaths from pr
Page 103 and 104:
publication from the United States
Page 105 and 106:
References 1 Knight M, Kurinczuk JJ
Page 107 and 108:
obstetricians and anaesthetists rou
Page 109 and 110:
Detailed guidelines for the managem
Page 111 and 112:
acute bleeding situation although i
Page 113 and 114:
References 1 Brace V, Penney G, Hal
Page 115 and 116:
Table 5.1 Direct deaths attributed
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of over ten litres. Despite a hyste
Page 119 and 120:
References 1 Clark SL, Pavlova Z, G
Page 121 and 122:
The women who died The ages of the
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A woman who had not been long in th
Page 125 and 126:
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
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8 Anaesthesia Griselda Cooper and J
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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
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What did you learn from this case a
Page 145 and 146:
9 Cardiac disease Catherine Nelson-
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Table 9.2 Causes of maternal death
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an estimated incidence of 1.1 per 1
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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
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Infectious endocarditis Two women d
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10 Other Indirect deaths Michael de
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Table 10.1 Causes of Other Indirect
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Fifty-eight of the eighty-seven wom
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Previous Reports have emphasised th
Page 167 and 168:
Aspergillosis usually occurs in imm
Page 169 and 170:
Liver disease There were four mater
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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 and 186:
Report, 26 deaths from suicide were
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Current psychiatric treatment In th
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12 Deaths from psychiatric causes S
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caring for the woman. Nonetheless,
Page 193 and 194:
Commentary on deaths related to dru
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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
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The mothers affected: 2003-05 Durin
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Of the women who were murdered: •
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Annex 13.1 The recommendations of t
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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
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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
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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
Page 237 and 238: Table 16.1 Poor or non attenders fo
Page 239 and 240: Action checklist for midwifery prac
Page 241 and 242: 17 Issues for General Practitioners
Page 243 and 244: Box 17.1 Summary of the key issues
Page 245 and 246: Box 17.3 Risk factors for venous th
Page 247 and 248: headaches. The indications for emer
Page 249 and 250: Box 17.8 GP learning points: Heartb
Page 251 and 252: medication after delivery and been
Page 253 and 254: Women with mitral stenosis may seem
Page 255 and 256: signifi cance in the pregnancy. It
Page 257 and 258: References 1 RCOG. Thromboprophylax
Page 259 and 260: Introduction For the fi rst time in
Page 261 and 262: measures were of a good or excellen
Page 263 and 264: A woman collapsed at home following
Page 265 and 266: never preclude requesting opinion f
Page 267 and 268: admissions represented 0.9% of all
Page 269 and 270: Modifi ed early warning scoring sys
Page 271 and 272: Box 19.3 Critical care learning poi
Page 273 and 274: her initial collapse she was transf
Page 275 and 276: Chapter 19 Annex A This Annex is av
Page 277 and 278: Table 20.1 Inclusion criteria used
Page 279 and 280: Table 20.3 Numbers and rates of sev
Page 281: References 1 Baskett TF,.O’Connel
Page 285 and 286: Verifi cation of Ascertainment Asce
Page 287 and 288: Scotland A single panel of assessor
Page 289 and 290: CEMACH Regional Managers East of En
Page 291 and 292: Regional Assessors in Pathology Eas
Page 293 and 294: NORTHERN IRELAND Department of Heal
Page 295 and 296: 267
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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