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

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264 APPENDIX 2: Assessors for the Maternal Deaths Enquiry for the triennium 2003-2005 and CEMACH Personnel South East Ms C Drummond RGN RM Ms S Sauter RM DNLS ADM Dip Ethics Ms A Weavers RM South West Mrs V Beale RN RM Dip Man MSc Mrs J Drury RM RN MSc DpSM SEN Ms D Morrall RN RM Mrs A Remmers RGN RM MSc West Midlands Mrs C McCalmont RN RM DPSM Mrs E Newell RGN RM DPSM BSc(Hons) Mrs S Smithson BSc(Hons) RN ADM ONC Yorkshire/Humber Mrs JM Jackson RN RM Ms J Lovett RGN RM Ms D Watkins RN RM ADM MSc SCOTLAND Chairman of Enquiry Professor MH Hall FRCOG Dr W Liston FRCOG Medical Coordinator: Scottish Programme for Clinical Effectiveness in Reproductive Health Dr G Penney FRCOG CMO’s Representative: Scottish Executive Health Department Dr I Bashford MRCOG Obstetric Assessors Professor MH Hall FRCOG Dr D A Lees FRCOG Dr WA Liston FRCOG Dr CB Lunan FRCOG Professor D Murphy MRCOG Dr H MacPherson FRCOG Professor J Norman MD FRCOG Anaesthetic Assessor Dr JH McClure FRCA Pathology Assessor Dr R Nairn FRCPath Midwifery Assessor Mrs J Reekie RGN RM
NORTHERN IRELAND Department of Health and Social Services: Northern Ireland Dr C Willis MB ChB BAO MFPH Obstetric Assessor Miss A Harper OBE FRCOG Anaesthetic Assessor Dr IM Bali MD PhD FFARCS Dr D Hill FCARCSI Pathology Assessor Dr G McCusker FRCPath Midwifery Assessor Mrs E Bannon RN RM BSc(Hons) MSc Mrs E Millar RN RM NDNC MHSCert WALES Welsh Assembly Government Dr J Ludlow FFPHM Obstetric Assessor Mr R Vlies FRCS(Ed) FRCOG Anaesthetic Assessor Dr P Clyburn FRCA Pathology Assessor Dr Lesley Murray FRCPath Midwifery Assessor Ms J Keats RN RM Mrs K McGrath SRN RM Dip Mid MSc (Health Management) CEMACH Board Professor M Weindling Chair Dr J Chapple Faculty of Public Health Mr R Congdon Chief Executive CEMACH Dr G Cooper Royal College of Anaesthetists Dame Karlene Davis Royal College of Midwives Ms S Golightly Director of Research and Development CEMACH Dr S Gould Royal College of Pathologists Dr S Hollins Royal College of Psychiatrists Dr Mary Macintosh Medical Director CEMACH (until April 2006) Dr J McAughey Royal College of General Practitioners Professor N McIntosh Royal College of Paediatrics and Child Health Mrs A Miller Programme Director CEMACH Professor A Templeton Royal College of Obstetrics and Gynaecology 265
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
Page 41 and 42:
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
Page 59 and 60:
Table 1.19 Direct and Indirect mate
Page 61 and 62:
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
Page 77 and 78:
Country of birth and migration A fa
Page 79 and 80:
Table A1.4 Direct and Indirect deat
Page 81 and 82:
Body mass index varies with age, be
Page 83 and 84:
2 Thrombosis and thromboembolism Ja
Page 85 and 86:
Pulmonary embolism Of the 33 women
Page 87 and 88:
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
Page 115 and 116:
Table 5.1 Direct deaths attributed
Page 117 and 118:
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
Page 123 and 124:
A woman who had not been long in th
Page 125 and 126:
7 Genital tract sepsis Ann Harper G
Page 127 and 128:
Sepsis in early pregnancy Six women
Page 129 and 130:
Box 7.3 Learning points: Sepsis in
Page 131 and 132:
Risk factors for, and the identifi
Page 133 and 134:
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 and 186:
Report, 26 deaths from suicide were
Page 187 and 188:
Current psychiatric treatment In th
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
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 and 288: Scotland A single panel of assessor
Page 289 and 290: CEMACH Regional Managers East of En
Page 291: Regional Assessors in Pathology Eas
Page 295 and 296: 267
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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