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

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256 APPENDIX 1: Method of Enquiry These processes are summarised in fi gure 1. Direct Notification to CEMACH Non-Pregnancy Associated Deaths CENTRAL ASSESSMENT Direct Deaths CEMACH Active Case Recovery Information sought from all involved professionals on MDR-1 Form by CEMACH Regional Office Indirect Deaths Late Direct Deaths Notifications Database Late Indirect Deaths ANONYMISATION Central Assessment Database Director of Maternal Death Enquiry Central Assessors (Chapter Authors) REGIONAL ASSESSMENT (Anonymised MDR-1) Coincidental Deaths ONS Direct Notifications Statistical Advice Late Coincidental Deaths ONS Linkage Recovered Cases Duplicate Cases Review by Director of Maternal Death Enquiry and CEMACH Senior Midwife IRREVERSIBLE ANONYMISATION Saving Mothers’ Lives Report
Verifi cation of Ascertainment Ascertainment is checked with reference to data supplied by ONS. This data are supplied in two forms: (i) Direct Notifi cations; these are deaths of women where “pregnancy” is mentioned anywhere on the ONS death registration. These cases are coded as a maternal death according to the International Classifi cation of Diseases, Injuries and Causes of Death tenth revision (ICD10). This would identify all women where pregnancy may have been a contributing factor to their death. (ii) Linkage Notifi cations; these are deaths of women where the name of the woman appeared on the registration of a birth in the current or preceding calendar year. This would allow for the identifi cation of women who had died up to 364 days following delivery. This data is cross-matched with the data that has been directly acquired by CEMACH. Any cases that have been identifi ed by one organisation but not the other would then be established. These outstanding cases are then further investigated to ensure that they are pregnancy-associated-deaths, and that they warrant inclusion in the Enquiry and then an enquiry initiated using the standard data collection form. Regional Assessment Each CEMACH region has one or more sets of Regional Assessors (RA) depending on requirements. Each set includes an obstetric assessor, midwifery assessor, pathology assessor, an anaesthetic assessor and a perinatal psychiatric assessor. Assessors are appointed for the term of the triennium (about 4 years, allowing for completion of assessment). Nominations for medical assessors are sought from the presidents of the Royal Colleges, and nominations for midwives are sought from the LSAMO. An RA must be an active clinical practitioner in the National Health Service (NHS), in the relevant speciality. If medical, the Regional Assessor should be at consultant level, or, if a midwife, must be at supervisory level. The Regional Assessor should have knowledge and experience of organisation of care, as well as the respect of his/her peers. It is important that the Regional Assessor is able to realistically commit enough time to assess and return enquiry forms in a timely manner. The position is honorary. The role of the Regional Assessor is to review the information reported in the MDR-1 form, and any other documents that have been assembled by the CEMACH Regional Manager. The Regional Assessor will then make a short report in the relevant section of the enquiry form. All the information provided to the Regional Assessor is anonymised. This report includes a comment on the case, an evaluation of the clinical management and the resources of the organisation responsible for the care of the woman. The assessor is also asked to make a judgement as to whether the care was substandard and, if so, if this was a contributing factor in the death of the mother. Central Assessment The Central Assessors review each case thoroughly, taking into account the case history, the results of pathological investigations, and fi ndings of autopsy that may have been conducted. Following this detailed investigation, each case is allotted to a specifi c chapter in the fi nal report. This assessment occasionally varies with the underlying cause of death as given on the death certifi cate, and classifi ed by the Registrars General using the ICD10. This is because a death may be coded for a specifi c cause-of-death, but the pathogenesis of this condition may have been precipitated by an obstetric event. For example, although a given death may be coded as multiple-organ failure as the terminal event, it could have been precipitated by an obstetric event such as septicaemia from an infected caesarean 257
Page 1 and 2:
Confidential Enquiry into Maternal
Page 3 and 4:
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
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of note is that every women who die
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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
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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
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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
Page 79 and 80:
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
Page 89 and 90:
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
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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
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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
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
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A woman suffered a concealed haemor
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Sepsis Poor anaesthetic or resuscit
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What did you learn from this case a
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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
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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
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her delivery, but her case should h
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Severe abdominal and back pain, sci
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References 1 Drife, J O. The contri
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Psychiatric deaths: Specifi c recom
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cut off point for maternal deaths,
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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,
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Commentary on deaths related to dru
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It is known that women presenting w
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antibiotics nor returned to her gen
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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
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
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association with obesity as eight o
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Obesity was present in 55% of these
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Toxicology showed non-lethal citalo
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Box 15.6 Pathology learning points:
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References 1 Royal College of Patho
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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
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 and 282: References 1 Baskett TF,.O’Connel
Page 283: The Director of the Maternal Death
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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