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St Helens & Knowsley Teaching Hospitals NHS Trust

St Helens & Knowsley Teaching Hospitals NHS Trust. Whiston Maternity Services Supervision following 3 Maternal Deaths – Midwifery Case Studies Val Blakemore, Ann Finch, Julie Pilkington and Sue Weston (Supervisors of Midwives). St Helens & Knowsley Teaching Hospitals NHS Trust. Case 1

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St Helens & Knowsley Teaching Hospitals NHS Trust

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  1. St Helens & Knowsley Teaching Hospitals NHS Trust Whiston Maternity Services Supervision following 3 Maternal Deaths – Midwifery Case Studies Val Blakemore, Ann Finch, Julie Pilkington and Sue Weston (Supervisors of Midwives)

  2. St Helens & Knowsley Teaching Hospitals NHS Trust Case 1 • R.H 36 years old. P4 – 3 previous ND • Diet controlled gestational diabetic – well controlled. • Case load for Student Midwife • IOL @ 38/40. • ND, home next day. • PN care uneventful • Found by Husband on day 14, collapsed and no sign of life.

  3. St Helens & Knowsley Teaching Hospitals NHS Trust SUI protocol initiated • Escalation to Head of Midwifery • SOM on call • Obstetric Consultant on call • Obstetric Clinical Director • Trust Executives

  4. St Helens & Knowsley Teaching Hospitals NHS Trust Review Outcome • Maternal Death Policy reviewed following incident. • Appropriate care found on review of health records by multidisciplinary team. • Found to have complained of abdominal pain – had appointment to see GP after weekend. • Post Mortem – Septicaemia and retrocaecal appendix abscess and noted pregnancy was coincidental to death.

  5. St Helens & Knowsley Teaching Hospitals NHS Trust Case 2 • D.J. 30 years old separated mother of five children. Had a home delivery 16/07/10 • She had been brought to A+E on the 22/12/10 by paramedic ambulance from her home having attempted suicide by hanging. Transferred to critical care for ventilatory support, despite best efforts diagnosis of brain stem death was made. Ventilatory support was discontinued.

  6. St Helens & Knowsley Teaching Hospitals NHS Trust • On 24/12/10 the Head of Midwifery was informed of the maternal death by the community midwife, investigation commenced and maternal death policy initiated. • Request for Hospital/Hand held records was made.

  7. St Helens & Knowsley Teaching Hospitals NHS Trust Findings • Late booker seen by CMW at the GP surgery and offered to book her that same day, no referral letter from GP. • Community booking no access to previous health records. • Psychological problems noted at booking but not elaborated on.

  8. St Helens & Knowsley Teaching Hospitals NHS Trust Findings • When DJ’s family were on A+E on 22/12/10 her father reported episodes of domestic violence, alcohol dependency and abuse of cocaine which had not been disclosed to maternity services • Contacted GP for CMACE report no history of mental illness disclosed.

  9. St Helens & Knowsley Teaching Hospitals NHS Trust Case 3 • L.S 29 year old Gravida 5 Para 3, 2 previous caesarean sections. • Type 1 Diabetic poor glycaemic control, non-compliant with care. Had diabetic nephropathy and retinopathy. Long term smoker. • Last delivery was on the 25/10/10 at 28 weeks gestation by emergency caesarean section for PPROM, low-lying placenta and contracting. Baby transferred to NNU.

  10. St Helens & Knowsley Teaching Hospitals NHS Trust • Transferred to the care of the Community Midwife on Day 4 post delivery • Hypertensive medication prescribed to take home.

  11. St Helens & Knowsley Teaching Hospitals NHS Trust • Admitted to A+E on 2 occasions in January and March 2011 with a history of frontal headaches, vomiting and blurred vision. • Diagnosis of severe migraine was made and treated accordingly – discharged home. • Admitted to A+E on 14/04/11 following a cardiac arrest at home. • Resuscitation performed but unsuccessful.

  12. Post Mortem findings – Acute myocardial ischaemia due to coronary artery atheroma Investigation of maternal death still in progress.

  13. St Helens & Knowsley Teaching Hospitals NHS Trust Supervisory Support • Provide immediate support to staff involved • Case 1 student support – Contact HEI • Offer support to complete factual report and involve in formal review • Review maternity records with the midwives involved • Nurture and encourage reflection of any lessons to be learned

  14. Supervisory Actions • Ensure all SOM are informed of the maternal death • Inform LSA and provide updates • Seek support for staff involved – Spiritual Care, Human Resources and Occupational Health Dept • Feedback meeting for all staff involved.

  15. Recommendations Case 1 • Maternal death policy checklist adapted Case 2 • Improve the availability of previous medical/obstetric history when booking in the community setting Case 3 • Investigation ongoing

  16. Thank You

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