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11 Maternal deathdoc - Guidelines for Supervisors of Midwives

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					    YORKSHIRE AND THE HUMBER LOCAL SUPERVISING AUTHORITY




                                                                             11
                          MATERNAL DEATH

   Paper copies of this guideline may not be the most recent version. The
         definitive version is held at www.yorksandhumber.nhs.uk




Guideline Written by: Supervisors Guidelines Group

Date: April 2007

Consultation process: Reviewed by the Supervisors Guideline Development
Group Yorkshire and the Humber at 1st and final draft stages and by CEMACH
Regional Manager.

Approved by: LSA Midwifery Officer, Chair of the Yorkshire and the Humber
Guidelines Group

Date: April 2007

Implementation date: May 2007

Review Date: November 2009




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                               MATERNAL DEATH

BACKGROUND

From 2006 The Confidential Enquiry into Maternal and Child Health (CEMACH)
became a four yearly report, providing an overview of the numbers and causes of
maternal death in the United Kingdom. CEMD and the Confidential Enquiry into
Stillbirths and Infant Deaths (CESDI) merged to form the Confidential Enquiry
into Maternal and Child Health (CEMACH) on the 1st April 2003. The work of
CEMACH is commissioned by the NPSA.

The collated and anonymised information shows where improvements in clinical
practice or service provision may help to prevent future deaths. It is therefore
important that all cases are notified promptly so that full information on each case
is readily available.

It is a statutory requirement that all health professionals provide information and
participate in confidential enquiries. Professionals are asked to:

   (i) To provide a full and accurate account of the circumstances leading up to
         the woman’s death, with supporting records
   (ii) To reflect on any clinical or other lessons that have been learned, either
         personally or as part of the wider institution, and
   (iii) To describe what action may have followed as a result.

The aims and objectives of the maternal deaths enquiry and the definitions of
maternal deaths can be found in Appendix 1.

This guideline outlines the initial key roles of:

 the supervisor notified of a maternal death
 the CEMACH supervisor of midwives (the nominated Trust supervisor who co-
  ordinates and liaises with the LSA and CEMACH offices)
 the LSA Midwifery Officer


IMMEDIATE ACTIONS – DIRECT MATERNAL DEATH IN HOSPITAL

The on call Supervisor of Midwives (SoM(s)) and Consultant on call should be
contacted and asked to attend. The key responsibilities of the supervisor of
midwives are to ensure that:

       the Consultant on call has been asked to attend. They should meet
        relatives as soon as possible. The women’s named Consultant should
        be informed when he/she is next on duty.


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      support and information is given to the immediate relatives/next of kin.
       Relatives may wish for religious or spiritual support. The Hospital
       Chaplain may be contacted if appropriate.
      the Coroner has been notified. The Coroner’s office should be contacted
       (cross reference your Local Policy for contact numbers). Out of hours a
       Coroner’s officer is available for emergencies (24 hour service)
        NB: The attending doctor cannot issue a death certificate without first
       referring for consideration by HM Coroner (The mortuary department
       should be informed that a maternal death has occurred and to expect the
       body without a death certificate).
      appropriate provision is made for the baby; social services involvement
       may be required on an individual basis.
      where there has been a stillbirth or early NND ensure local guidelines
       and checklists are followed.
      the senior clinician present has informed the family that it is not possible
       to issue a death certificate without consideration of post-mortem by the
       Coroner.
      the Serious Untoward Incident Policy has been initiated and details of
       the incident made available (if appropriate a Root Cause Analysis (RCA)
       will be undertaken by the Risk Management Team, a SoM must be
       involved in the RCA (cross reference Reporting and Monitoring of
       Serious Untoward Incidents, Investigation of Incidents and the Role of
       the LSA)).
      the medical records should be reviewed and the SoM involved should
       complete a summary of the case. It is important to note the names of all
       staff involved, particularly those staff that do not normally work with the
       Maternity Unit (i.e. Operation Department Assistant (ODA) or Operation
       Department Practitioner (ODP), crash teams, attending anaesthetists
       etc.).
      the case notes and all relevant documentation, including cardio
       tocographs, have been photocopied and secured at the first opportunity,
       identifying them as photocopies with the date they were produced so that
       they will not be mistaken as the original notes. There should be an early
       review of the records; the midwifery care given should be reviewed by
       the SoM.
      that appropriate support is offered to the staff involved. Personnel such
       as the staff counsellor or Hospital chaplain may support the SoM with
       this. The SoM may need addition support from a SoM colleague.
      the CEMACH supervisor of midwives, the Head of Midwifery (HoM) and
       the LSA Midwifery Officer (LSAMO) should be informed as soon as
       possible within normal working hours.

Appendix 2 offers a checklist that may be used.




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IMMEDIATE ACTIONS – DIRECT MATERNAL DEATH IN PRIMARY CARE

The woman’s midwife is responsible for ensuring that a SoM is informed of any
maternal death that comes to her attention in the Primary Care setting. The SoM
will notify the HoM and the LSA. CEMACH will be notified by the LSA Office.

Maternal deaths are normally notified related to the woman’s area of residence
but, if in doubt, always notify to the LSA.

The GP should also have notified the Hospital if the woman has delivered or
received care there.

In situations where a maternal death has occurred previously on notification
follow the flow chart in Appendix 3.


ROLE OF THE CEMACH SUPERVISOR OF MIDWIVES

         The CEMACH SoM may need to be released from duties to undertake
          this role.
         The CEMACH SoM should ensure that the local Trusts policies have
          been followed.
         The death is reported as a Serious Untoward Incident (SUI). This is
          usually undertaken via the Trusts Governance leads.
         The death will be reported the Local Supervising Authority Midwifery
          Officer (LSAMO) as soon as practicably possible initially verbally
          followed by the maternal death proforma.
         The SoM should ensure communication takes place within and across
          the primary and secondary sector, including the family GP, and any
          other statutory agency connected to the family.
         The CEMACH SoM will arrange a debriefing of all staff involved.


OTHER DEATHS (INDIRECT, CONICIDENTAL AND LATE)

All other deaths should be dealt with on an individual basis as these may include,
murder, suicide, road traffic collision, women with known terminal illness.


COMPLETING THE ENQUIRY FORM

On being informed of the maternal death the CEMACH Regional Manager will
forward the Enquiry Form (MDR1) along with a covering letter, instructions for
staff completing sections of the report and notes for the completion of the report.

On receipt of the booklet it is essential that the CEMACH SoM tracks the
progress of the booklet internally and seeks to have the booklet returned to the
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Regional Manager at the earliest convenience, but no later than three months
after notification.

In order to preserve anonymity and prevent the possibility of a legal subpoena,
no photocopies of statements sent with or attached to the confidential enquiry
form or photocopies of the confidential enquiry form should be made at any time.

The key roles of the LSA Midwifery Officer:

   support and advice to supervisors
   liaison with the CEMACH Regional Office
   collation of numbers, themes and trends within LSA annual report
   appropriate liaison with the SHA and across the LSA of lessons learnt



WHERE TO GO FOR FURTHER ADVICE

CEMACH - East Midlands/ Yorkshire and Humberside Office

Mrs Sue Wood - Regional Manager
Heeley Suite
Blades Enterprise Centre
John Street
Sheffield
S2 4SW
e-mail: sue.wood@cemach.org.uk
Tel: 0114 292 2492

Clare Platts – Assistant Regional Manager
Address as above
Tel: 0114 292 2491


Yorkshire and the Humber Local Supervising Authority
Carol Paeglis
LSA Midwifery Officer
NHS Yorkshire and the Humber
Blenheim House
West One
Duncombe Street
Leeds LS1 4PL
email: carol.paeglis@yorksandhumber.nhs.uk
Tel: 0113 295 2094
Mobile: 07748 362320




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REFERENCES
www.CEMACH.org.uk

CEMACH (Nov. 2004) Why Mothers Die2000 -2002. Confidential Enquiry into
Maternal and Child Health, The sixth report of the confidential Enquiries into
Maternal Deaths in the United Kingdom, RCOG Press, London.

Local Guideline – “Reporting and monitoring of serious adverse events,
investigation of incidents and the role of the LSA” (2005)

CEMACH (June 2006) Maternal Deaths Enquiry Protocol, CEMCH




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The aims and objectives of the maternal deaths enquiry are:                       APPENDIX 1

       to assess the main causes of and trends in maternal deaths; to identify
        any avoidable or substandard factors; to promulgate these findings to all
        relevant health care professionals
       to improve the care that pregnant and recently delivered women receive
        and to reduce maternal mortality and morbidity rates still further, as well as
        the proportion of deaths due to substandard care
       to make recommendations concerning the improvement of clinical care
        and service provision, including local audit, to purchasers of
        obstetric services and professionals involved in caring for pregnant and
        recently delivered women
       to suggest directions for future areas for research and audit at a local and
        national level
       to produce a four yearly Report on behalf of CEMACH in England and
        Wales for the NPSA, on behalf of the Scottish Programme for Clinical
        Effectiveness in Reproductive Health acting for the Scottish Executive
        Health Department and on behalf of the Department of Health, Social
        Services and Public Safety for Northern Ireland (DHSSPSNI)
       to review methodologies for enquiry into maternal deaths
       (pg 2, Maternal Deaths Enquiry                Protocol, CEMACH 2006).

DEFINITION OF A MATERNAL DEATH

Deaths of women while pregnant or within 42 days of delivery, miscarriage or
termination of pregnancy, from any cause related to or aggravated by the
pregnancy or its management, but not from accidental or incidental causes. In
addition CEMACH require notifications of suicides, and deaths due to
misadventure and cardiomyopathy up to six months post-delivery.

 Direct – a death resulting from obstetric complications of the pregnant state
(pregnancy, labour and puerperuim), from interventions, omissions, incorrect
treatment, or from a chain of events resulting from any of the above.

Indirect – a death resulting from previous existing disease, or disease that
developed during pregnancy and which was not due to direct obstetric cause, but
which was aggravated by the physiological affects of pregnancy.

Late – a death occurring between 42 days and one year after termination of
pregnancy, miscarriage or delivery that are due to direct or indirect maternal
causes.

Coincidental – a death that occurs from unrelated causes, which happens to
occur in the pregnancy or puerperium e.g. road traffic accident.

Pregnancy related deaths – a death occurring in women while pregnant or
within 42 days of termination of pregnancy, irrespective of cause of death.
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APPENDIX 2
                                  MATERNAL DEATH CHECKLIST




                                                                                               signature
     Actions                                                                            Date




                                                                                               ?
     ? inform next of kin if not present


     Contact the Consultant on call.

     During working hours contact the Named Consultant


     Contact the on call SoM to provide support


     Ensure all records are completed

     Photocopy and secure medical notes at the earliest opportunity

     The serious untoward incident Policy should be instigated where appropriate.

     Adverse Incident form should be completed


     Where there has also been a stillbirth/Early Neonatal death local guidelines and
     checklists should be utilised.


     The coroner’s office should always be notified. A Death certificate cannot be
     completed until consideration has been given by the Coroner.
     Local Coroners advice is available 24 hours Tel.___________ (enter local number.


     Inform the mortuary that a death has occurred and a body will be sent without a
     Death certificate.



     Has a death certificate been completed?


     Inform the following ASAP? in working hours ? next day:-

     Clinical/ Ward Manager

     Named Consultant


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SoM CEMACH coordinator

Head of Midwifery

Directorate Clinical Director

Trust Medical Director

Trust Chief executive

Directorate Risk Manager

Trust Risk Manager

Director of Nursing

General Manager

GP

Community Midwife

Health Visitor

Social services if live baby requires care and the family support

Strategic Health Authority Clinical Governance lead

Director of Public Health - local PCT

CEMACH Regional Manager - inform if baby also died

Lead Midwife for Education (LME) at the University if a student midwife has been
involved in any way

The CEMACH Regional Manager must be informed on the next working day.

Where the woman has received care in different areas discuss with the Regional
Manager how this will be progressed.

Sue Wood - 0114 292 2492

Inform the LSA Midwifery Officer as soon as possible.

Submit a brief report with details of any supervision/practice/support issues as well
as a precise description of events.

Regular progress reports should be given

Where the woman was booked in, or had received treatment in another area
inform the hospitals;

Consultant
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Head of Midwifery

Supervisor of Midwives

 Identify a member of staff to act as a support for the family and provide
information

Offer Religious support for the family

 Have the relatives met with the consultant




Debriefing arranged for the staff involved



Case notes and documentation sent to the Coroner’s office




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APPENDIX 3   YORKSHIRE AND THE HUMBER LOCAL SUPERVISING AUTHORITY


         Flowchart

                                   Supervisor on call notified of maternal death



                                  Attend if being informed of the death at time of
                                     occurrence and woman in maternity care
                                                       setting.



                              Collect all necessary information as soon as possible:

                              Name, DOB, Address, GP.

                              Details of delivery, including EDD and parity.

                              Date of death, place of death, provisional cause of
                              death, Consultant obstetrician.

                              Obtain copy of maternity notes.




               Notify LSA Midwifery Officer                     Meet with nominated SOM for co-
               Carol Paeglis - 0113 295 2094                      ordinating maternal deaths
               Mobile - 07748 362320




                                                             Complete checklist
                 LSA Notifies:-
                                                            Notify:-
                  Sue Wood, CEMACH                         GP and HV if not already involved
                   Regional Manager - 0114 292               or aware,
                   2492.                                    Social Services if they have had
                  Margaret Jackson, Associate               any involvement in family
                   Midwifery Assessor                       Consultant in charge of obstetric
                                                             care
                                                            Director of Public Health of local
                                                             PCT (for information only)




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