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

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1 Which mothers died, and why
The quality of care the women received
Sub-standard care remained very diffi cult to evaluate in many of the cases in this Report due to the lack
of key data from some records and case notes. Whilst it is clear that many of the cases received less than
optimum care, it has not always been possible to quantify these with certainty. Box 1.2 gives the defi nitions
of sub-standard care used in this Report.
Box 1.2
Defi nitions of sub-standard care used in this Report
Type Defi nition
Major
Minor
Contributed signifi cantly to the death of the mother. In many, but not all cases different
treatment may have altered the outcome.
It was a relevant contributory factor. Different management might have made a
difference but the mother’s survival was unlikely in any case.
Despite the limitations, the assessors classifi ed 64 % of Direct deaths and 40% of Indirect deaths
as shown in Table 1.11 as having some degree of substandard care. Table 1.12 gives the degree of
substandard care compared to the previous two Reports. The overall rate of sub-standard care for women
dying of Direct causes has fallen a little compared to the 67% reported for the last triennium whilst there
has been a very small rise in the rate for Indirect deaths. By contrast, only about 10 % of both Coincidental
and Late deaths had elements of sub-standard care. The major concerns about the care provided for these
groups of women were a lack of liaison and communication between the health and social services in
providing support for vulnerable young girls and a lack of multidisciplinary or co-ordinated care.