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

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260 APPENDIX 2: Assessors for the Maternal Deaths Enquiry for the triennium 2003-2005 and CEMACH Personnel Director of Enquiry Dr G Lewis MSc MRCGP FFPH FRCOG Central Assessors and authors Obstetrics Professor J Drife MD FRCIG FRCP(Ed) FRCS(Ed) FCOG(SA) Professor J Neilson MD FRCOG Anaesthetics Dr G Cooper OBE FRCA FRCOG Dr JH McClure RCA Intensive Care Dr T Clutton-Brock MRCP FRCA Pathology Dr GH Millward-Sadler FRCPath MHSH Medicine Professor M de Swiet MD FRCP FRCOG Dr C Nelson-Piercy FRCP FRCOG Midwifery Dr G Edwards RN RM ADM Cert Ed Med PhD Dr J Rogers BA PhD DPSM SRN RM Mrs V Beale RN RM Dip Man MSc Psychiatry Dr M Oates DPM FRCPsych General Practice Dr J Shakespeare MRCP FRCGP Emergency Medicine Dr D Hulbert FRCS FFAEM CEMACH personnel involved in Enquiry work Central Offi ce Chief Executive Mr R Congdon Director of Research and Development Ms S Golightly Programme Director Mrs A Miller Administrative Offi cer Mrs M Wilson
CEMACH Regional Managers East of England Mrs C Hay East Midlands Mrs S Wood London Mrs S Roberts Mrs V Clements Mrs R Thomas South East Miss M Gompels South West Mrs R Thompson North East Mrs M Renwick Northern Ireland Dr M Scott Dr A Bell North West Mrs J Maddocks Wales Mrs J Stewart Mrs J Hopkins Mrs D Roberts West Midlands Mrs P McGeown Mrs J Maddocks Yorkshire and Humber Mrs L Anson Mrs S Wood Regional Assessors in Obstetrics East of England Mr B Lim FRCOG FRANZCOG East Midlands Miss HJ Mellows FRCOG London Miss G Henson FRCOG Mr ME Setchell FRCS FRCOG Mr GHW Ward FRCOG FRANZCOG North East Professor JM Davison MD FRCOG North West Miss P Buck FRCOG Mr SJ Duthie FRCOG Mr S Walkinshaw FRCOG South East Miss P Hurley FRCOG Miss C Iffl and FRCOG Dr K Morton FRCOG 261
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
Page 5 and 6:
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
Page 15 and 16:
Early warning scoring system 9. The
Page 17 and 18:
References 1 Redshaw M, Rowe R, Hoc
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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
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Figure 1.1: Overall maternal mortal
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Coincidental deaths The deaths of 5
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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
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
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Table 1.22 Characteristics of the a
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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
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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
Page 105 and 106:
References 1 Knight M, Kurinczuk JJ
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obstetricians and anaesthetists rou
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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
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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
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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
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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
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Aspergillosis usually occurs in imm
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Liver disease There were four mater
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Diseases of the circulatory system
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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
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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
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Table 14.2 Late deaths known, or no
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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
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effective service for women who may
Page 231 and 232:
Professional accountability and com
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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 and 284: The Director of the Maternal Death
Page 285 and 286: Verifi cation of Ascertainment Asce
Page 287: Scotland A single panel of assessor
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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