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

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vi Acknowledgements Thanks are due to all the health care professionals and staff who assisted with the individual cases and who have contributed their time and expertise and without whom this Report would not have been possible. With their help this Enquiry remains an outstanding example of professional self-audit, and will continue to improve the care provided to pregnant and recently delivered women and their families. In particular, thanks are due to: • All Central Authors and Assessors, and other authors and contributors • All Regional Assessors • The Offi ce of National Statistics • All CEMACH Regional Managers and Assistants for liaising with local clinicians and managing the data collection process (listed in Appendix 2) • The National Perinatal Epidemiology Unit (NPEU) for providing external review to this Report, and in particular, Jenny Kurinczuk • Rosie Houston, Projects Manager, for managing the publication of this Report • Shona Golightly, Director of Research and Development; Richard Congdon, CEMACH Chief Executive; Dharmishta Parmar, Data Manager and all other staff at CEMACH Central Offi ce for their support and advice during the development of this Report.
Foreword Having a baby is a joyous and fulfi lling experience and, nowadays, a safe one for the great majority of women in the United Kingdom. This safety has been hard won. It is the result of many years of painstaking work to identify and reduce risks, and to defi ne the best treatment when complications do occur. Nevertheless some mothers still die, and these deaths are all the more shocking because they are now so uncommon. It is our duty to learn all we can from such tragedies. Confi dential enquiries into maternal deaths began in England and Wales more than fi fty years ago and have covered the United Kingdom since 1985. The triennial reports have become essential reading for health professionals, and a model for similar enquiries in many other countries. The Enquiry, however, is continually evolving and the present report has a new title, Saving Mothers’ Lives. The previous name, Why Mothers Die, failed to emphasise that these reports not only describe the reasons for maternal mortality but also make important recommendations to reduce the risk of death in the future. We are concerned that the UK maternal mortality rate has not fallen in recent years. This is partly due to the changing nature of our mothers’ overall health. In general, the women who died appeared to be in poorer general health and smoked more, and over half were overweight or obese. Many also had chaotic lifestyles and found it hard to engage with maternity services. The rate is almost certainly infl uenced by the increasing number of deaths amongst migrant women, whose numbers have also risen. For this triennium the Report not only identifi es areas of substandard care but also, even though the overall percentage of such cases has not increased, includes for the fi rst time a list of ten overall recommendations highlighting the key issues to be addressed as a matter of priority by commissioners, providers and policymakers. We expect these, and the other recommendations in the Report, to lead to action. Other innovations include contributions from a general practitioner and a consultant in emergency medicine. These new chapters emphasise the need for wider awareness of risk factors and early signs and symptoms of problems which may be crucial in pregnancy. The broad range of specialties represented in the writing panel refl ects the teamwork required in modern maternity care. The team also includes the woman herself. Women who are socially excluded, such as asylum seekers or homeless people, have a disturbingly high risk of death. Publication of this report has been achieved on schedule despite pressures from health service reorganisation. This is due to the hard work and enthusiasm of many people but we are particularly grateful to Dr Gwyneth Lewis, the National Clinical Lead for Maternal Health and Maternity Services in England. As well as directing the UK Enquiry and making insightful innovations she has personally collated the data and prepared the report. We thank her for her continuing commitment and dedication. Saving Mothers’ Lives has important messages for everyone involved in maternity care. It is essential that we do not become complacent. Although some maternal deaths are unavoidable, other women are still dying needlessly in the UK. This can be prevented in future only if lessons are learned and acted upon, and the process begins here. Sir Liam Donaldson Chief Medical Offi cer – England Dr Michael McBride Chief Medical Offi cer – Northern Ireland Dr Tony Jewell Chief Medical Offi cer – Wales Harry Burns Chief Medical Offi cer – Scotland vii
Page 1 and 2: Confidential Enquiry into Maternal
Page 3 and 4: Saving Mothers’ Lives: Reviewing
Page 5: Contents Maternal deaths Indirectly
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
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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
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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 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 and 292:
Regional Assessors in Pathology Eas
Page 293 and 294:
NORTHERN IRELAND Department of Heal
Page 295 and 296:
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