Date

London Maternal Mortality Learning and

Sharing event

London Maternal Morbidity & Mortality

Working Group

8th September 2016

Date

Welcome and introductions

Donna Ockenden, Chair of the London Maternal Morbidity & Mortality Working Group

London Maternity Clinical Network

8th September 2016

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Delegate Information Packs

• Event programme

• Report – London maternal deaths – a 2015 review

• LAS maternity prehospital screening and action tool

• Maternity management plan tracker MDT

• Maternity Transformation Programme – 5 key work streams and London implementation

• Evaluation form – please complete!

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Aims of the day

• The report – presentations on the key themes

identified, case studies and recommendations

• An opportunity to have interactive discussion after

each session Share learning from the case reviews

• Take home messages to your organisations to assist in

reducing maternal mortality in London

• An opportunity to have an open and honest

discussion about the findings and cases

• Ensure confidentiality from the discussions, particularly

around individual cases

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Dedication

This report and event is dedicated to the 26 women who died and the 26 families

who lost a wife, partner, sister, mum, daughter, best friend. It reminds us of our responsibility to ensure

that wherever possible the learning from this report is shared widely across London and, where it can, it

makes a difference to the care provided to the women of today and tomorrow

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Through this London-wide work – we will remember them

Date

Session One Overview of maternal

mortality

Donna Ockenden Co Clinical Director London Maternity Clinical Network

Caroline Moren, Senior Project Manager London Maternity Clinical Network

Penny Law Consultant Obstetrician & Gynaecologist, The Hillingdon Hospital NHS Foundation Trust

8th September 2016

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Thank you!

A big thank you to all the

contributors to the report, the Maternal Morbidity and Mortality group members, the expert panel

members and the maternity units for implementing the new process

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Background

AIM: to address the reduction in maternal mortality and severe morbidity in London - a key focus area for the London Maternity Network • To ensure objective investigation, consistency and

London-wide learning from these tragic events

• Prior to July 2015 no agreed single London-wide process for the investigation of maternal deaths

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• Considerable variation of external input included in

investigation panels

• No consistent resource in the capital for units to easily and quickly identify suitable experts

• Introduction of a new, collaborative London-wide system for reviewing maternal death serious incidents (SIs) across the capital in July 2015

Background- 2

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Process for review of maternal deaths in London

• London maternal morbidity and mortality working

group set up in early 2015, a subgroup of the London Maternity Clinical Network

• Improve sharing and learning across all healthcare providers in the capital

• Membership via submission of expressions of interest to join the group

• As with all subgroups, individual expertise in the field was key, not geographical location

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• Standardised template for investigation of maternal death is in use in London maternity units

• Guidance document (Appendix 1) in packs to provide relevant information for the new process

• • We ask all London trusts to endorse this initiative to

ensure that following a maternal death all services are able to benefit from the support, expertise and objectivity this process brings

• National interest in our process – rollout?

Process - 2

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Expert panel member recruitment • As previously expressions of interest to become an

expert panel member • Requirement: to bring objectivity and expertise to

panels Feedback from maternity units • Survey monkey conducted with all Trusts who

received assistance from the new process.

• Once new process is fully implemented the network can focus on severe maternal morbidity for 2016/17

Process -3

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Survey of new process • 8 Trusts responded to survey monkey request • Questions centred on: • ease of contacting Clinical Network (CN) and

external experts • support from the CN • knowledge and expertise of the expert panel

members • usefulness of the new process, template and

guidance

• 1-5 scoring system used (1 being poor, 5 being good)

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Results of survey

• The majority of respondents scored 4-5 and comments received below:

• Some formatting issues with RCA template

• Quite difficult to contact expert panel members during holiday times

• Request to have the action plan in landscape format

• Challenges with investigations where contributions required from 2 trusts – would be helpful to have a 1 page inclusion of what expectations would be from both trusts

• All of these comments will be taken to the M&M group for review of the guidance document in September 2016

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Report production • Calendar year (Jan-Dec) in line with MBRRACE

reporting period • Annual reports going forward • Thematic review undertaken by group members by

interrogation of the SI reports for cases • Common themes extracted following

multidisciplinary discussion • Group evidenced notable practice and areas of

learning directly from the RCA within reports • Group has made no assessment of care from the

reports (as may be the remit of MBRRACE, for example).

• Original case notes were not reviewed.

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The London picture • Population of London now over 8.6 million –

expected to continue to grow to more than 10 million over next 20 years

• Over 600,000 London children living in poverty • Newham has the highest proportion of births in the

UK born to non-UK born women • Significant health inequalities are prevalent across

the London boroughs. • London has lowest birth rate for teenagers and

highest birth rate for women over the age of 45 years • Mobile population – relatively high fluctuation

compared to rest of UK

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Definitions of maternal death Direct deaths: Resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above. Indirect deaths: Resulting from previous existing disease, or disease that developed during pregnancy and which was not the result of direct obstetric causes, but which was aggravated by the physiological effects of pregnancy Coincidental deaths: From unrelated causes which happen to occur in pregnancy or the puerperium Late deaths: Occurring between 42 days and one year after the end of pregnancy that are the result of direct or indirect maternal causes

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Report findings This report: • Identifies lessons that can be learned on a system-

wide level and highlights where care may not be in line with best practice

• Brings together learning from all the reports that have been submitted to the clinical network for maternal deaths in 2015

• Provides insight into maternal deaths for the capital, most especially a pattern of women who have presented with severe pre-existing medical complexities

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Emerging themes • Social isolation and the pregnancy journey for

women with very complex co morbidities already in place

• Complexity of maternity cases in London increasing year on year

• Three of the maternal deaths that occurred were of women with significant co-morbidities who were transferred into London for specialist services

• The number of women dying due to indirect causes has increased

• Reflective of what is occurring elsewhere in the UK. • Causes of death usually multifactorial

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• Some recommendations link with the best practice toolkits that the London Maternity Clinical Network has produced (for example, continuity of care) to address elements of shared learning

• Areas where learning from existing MBRRACE

reports could have helped if recommendations had been implemented locally

Emerging themes - 2

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Themes identified overview

• Communication and coordination of care across settings

• Medical risk factors and complex cases • Sepsis • Identification of deterioration and escalation • Social risk factors and mental health • Delays in care along the pathway and out of

hours

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Maternal deaths in London 2015

Teamworking

• pre-hospital

• emergency department

• escalation

• specialist to specialist communication

• un-rostered staff coming in to assist/support

• on-going family support

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Social Isolation

• consider risk and vulnerability

• make every interaction count

• missed appointments

• inter-team communication- in/out of hospital

• post natal handover of care

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Co-Morbidity

• co-morbidity plus raised BMI

• co-morbidity plus sepsis

• specialist awareness of role of pregnancy plus chronic disease

• pre-conception counselling

• patient autonomy

• management plans

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Recognition of the sick patient

• ongoing training -MDT training

• auditing of guideline adherence

• escalation of abnormal signs ( respiratory rate )

• SEPSIS SIX-2006 in first hour

• 02

• Blood cultures

• IV Antibiotics

• FBC and lactate

• Urine output

• IV Fluids

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Documentation

• early warning charts--MEOWS

• comprehensive use throughout department / hospitals/region

• escalation

• adherence to guidelines for use

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Indirect Causes

• 19 women

• 23 post natal deaths

• post natal period - handover of care

• mental health - perinatal health networks, accessibility of care for pregnant women- resources

• suicide

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Communication

• pick up the phone

• specialist to specialist

• management plans in advance of delivery/admission/surgery

• escalation /patient transfer/ inter-hospital transfer

• patient communication

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Out of Hours

• involvement of other specialist teams

• not all teams on site

• escalation of therapy

• advance management plans - timing of delivery/surgery/therapy

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Reducing deaths for 2017

• Remember and share these cases

• recognition of the sick patient

• escalation and communication to all teams

• re visit guideline adherence if appropriate

• plan therapy in advance

• involve the woman but respect autonomy

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