Maternal Death. June 2012 (updated Jan 2013) Guidelines for Supervisors of Midwives. North of Scotland Local Supervising Authority Consortium

Transcription

1 Maternal Death Guidelines for Supervisors of Midwives June 2012 (updated Jan 2013) North of Scotland Local Supervising Authority Consortium

2 Guideline produced by: Supervisors Quality Improvement Group (SQIG) Guideline production date: Version 1 December 2008 Version 2 June 2012 (updated Jan 2013) Consultation process: North of Scotland LSA Consortium Healthcare Improvement Scotland Draft reviewed by: SQIG Guideline approved by: North of Scotland LSA Consortium Guideline approval date: 20 th August 2012 Guideline Implementation date: 20 th August 2012 Guideline review date: June 2015 Paper copies of this guideline may not be the most recent version. The definitive version is held at 2

3 Contents Introduction... 4 Definitions... 5 Maternal death... 5 Direct deaths... 5 Indirect deaths... 5 Coincidental deaths... 5 Responsibility for reporting a maternal death... 6 Guidance on completing the MDR1 enquiry form... 7 Fetal death due to maternal death... 8 Responsibilities of the Supervisor of Midwives... 8 Appendix 1 - Local Contact Details Appendix 2 - How to return maternal death information securely to the Confidential Enquiry into Maternal Health Appendix 3 - Check List

4 Introduction Local Supervising Authorities (LSA) are organisations within geographical areas, responsible for ensuring that statutory supervision of midwives is undertaken according to the standards set by the Nursing and Midwifery Council (NMC) under article 43 of the Nursing and Midwifery Order , details of which are set out in the NMC Midwives rules and standards 2. In Scotland, the function of the LSAs is provided by the Health Boards, which are arranged into two Regions the South East & West of Scotland and the North of Scotland. Each LSA Region has an appointed LSA Midwifery Officer (LSAMO) to carry out the LSA function. The LSAMOs are practising midwives with experience in statutory supervision and provide an essential point of contact for supervisors of midwives to consult for advice on aspects of supervision. Members of the public who seek help or support concerning the provision of midwifery care, can also contact the LSAMO directly. LSAMOs provide leadership, support and guidance on a range of matters including professional development. They also contribute to the wider NHS agenda by supporting public health and interprofessional activities at Health Board level. The purpose of this guideline is to explain the mechanism by which NHS organisations, private sector providers and midwives working independently will notify, via the Supervisor of Midwives (SOM), the Local Supervisory Authority Midwifery Officer (LSAMO) of a maternal death. The notification of these deaths is important from the aspect of wider public health. All deaths which occur during pregnancy (any gestation) and up to one year after the birth of the baby or when the pregnancy ends are currently classified as maternal deaths in Scotland and should be reported to the Confidential Enquiry into Maternal Health (CEMH) via the Reproductive Health Programme of Healthcare Improvement Scotland contact details in Appendix 1. 1 The Nursing and Midwifery Order. SI 2002 No Available online at 2 NMC 2012, Midwives rules and standards. London: NMC 4

5 Definitions Maternal death A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes 3. The Confidential Enquiry into Maternal Health (CEMH) in Scotland also recognises late maternal deaths which occur between 42 days and one year after delivery. For the purpose of the Enquiry, deaths are subdivided into a number of categories: Direct deaths A direct death is a death during pregnancy or within 42 days of delivery, termination or abortion 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 e.g. thrombosis. Indirect deaths An indirect death is a death during pregnancy or within 42 days of delivery, termination or abortion resulting from previous existing disease, or disease that developed during pregnancy and which was not due to obstetric causes, but which was aggravated by the physiological effects of pregnancy e.g. cardiac disease. These deaths include cases of self-harm as a consequence of postnatal depression. Coincidental deaths A coincidental death is a death which occurs during pregnancy or within 42 days of delivery, termination or abortion from unrelated causes e.g. road traffic accidents. The term coincidental is now preferred to fortuitous as being more appropriate and sensitive. 3 International statistical classification of diseases and related health problems, 10 th Revision. 2 nd edition, Volume 2 Instruction manual. Geneva: World Health Organization

6 Late deaths A late death is a death that occurs between 42 days and 1 year after delivery, termination or abortion that are due to direct or indirect causes. All deaths occurring during pregnancy or up to 12 months after delivery should be reported to the Scottish CEMH. Responsibility for reporting a maternal death A maternal death may occur in the community or in the hospital. The Enquiry is normally initiated by Healthcare Improvement Scotland Confidential Enquiry into Maternal Health (CEMH) administrator (see appendix 1 for contact details), who is usually informed of the maternal death by the National Records of Scotland or a health professional involved in the case. The responsibility for notifying the Director of Public Health for the area in which the woman resided should rest with the consultant, midwife, or general practitioner who had overall responsibility for the woman s care during pregnancy: or with the consultant or general practitioner treating the woman during her final illness if the death occurs within twelve months following the end of her pregnancy. It does not matter if more than one professional notifies the CEMH administrator as case ascertainment is more important than duplication of notifications. Reporting the death Please telephone the CEMH administrator at Healthcare Improvement Scotland to notify them of the death (see appendix 1 for contact details). Have the woman s notes with you if possible. It may be helpful for you to take a photocopy of the notes at this stage for future reference as notes are rarely available when you need them later. You will be asked for the following details of the woman: Postcode and address Date of birth Date of death Suspected cause of death Place of death GP name and contact details including post code and telephone number Booking hospital EDD Date of delivery Place of delivery 6

7 Pregnancy outcome Obstetric consultant and other relevant key health professionals involved with the case Short details of the case The type of death reported to the Enquiry (i.e. which sub-category) will direct the level of information that is then required for the assessment process. The CEMH administrator will discuss the need for completing a maternal death enquiry form (MDR1 4 ). If required, the MDR1 form will be sent to you by the CEMH administrator. Guidance on completing the MDR1 enquiry form A letter will accompany the MDR1 giving details of any specific information required and the date for return of the MDR1 to the CEMH administrator at Healthcare Improvement Scotland. Please ensure that the deceased s maternity records are photocopied and provided along with the completed MDR1 form. Other relevant notes, such as Emergency Department notes, intensive care notes and primary care notes, should also be provided where available. Where the place of death, place of booking and / or place of delivery were different from each other, the CEMH administrator will obtain the appropriate information independently from each place of care. Page 2 of the MDR1 provides you with a checklist of the documentation required to enable the enquiry assessors to make a full and appropriate assessment of the factors leading up to and surrounding the death of the woman. Please send a photocopy of these records when returning the completed MDR1. Pages 3-6 provide guidance for completion of the MDR1. Please read this before co-ordinating the completion of the MDR1 as it will ensure you provide the most appropriate details for this woman s type of death and minimise the need for the CEMH administrator to contact you for further information at a later date. Sections 1-4 should be completed for all women. 7

8 Sections 5-16 should be completed as indicated in the checklist (page 2). It is important that it is a clinician who was involved or has direct insight into the care of the woman who completes the MDR1, this is to ensure provision to the Enquiry of the most relevant information and to allow the self reflection question to be answered. E.g. if there was anaesthetic involvement in the case it should be an anaesthetist who completes section 13 of the MDR1. Once the MDR1 is completed and all the requested documentation collated, including, where relevant, the local serious untoward incident (SUI) review or Significant Clinical Event Analysis (SCEA), please return all the relevant paperwork to the CEMH administrator at Healthcare Improvement Scotland via recorded delivery as outlined in appendix 2. Fetal death due to maternal death In the event of the fetus dying in the uterus the following should be taken into consideration. The definition of a stillbirth does not include the removal of a dead fetus from its dead mother at post-mortem for the purpose of ascertaining the cause of death. This is because the post-mortem is being carried out on the mother rather than the fetus. Therefore, even if the gestation of the fetus is 24 weeks registration of the death is not legally required. However, consideration must be shown to the wishes of the family. A medical practitioner may issue a death certificate for the dead baby as stillborn. Most Registrars of Births, Deaths and Marriages will comply but local policies in this respect should be checked in order to prevent confusion and further distress for the family. As the majority of pathologists will remove the baby from the mother's body at post-mortem it is sensible for the local stillbirth/neonatal death procedure to be followed whether the baby is to be registered as a death or not. The Local Supervising Authority Midwifery Officer (LSAMO) must be informed as soon as possible on the next working day. Responsibilities of the Supervisor of Midwives The Supervisor of Midwives (SOM) will ensure that appropriate support is offered to the staff involved. Personnel such as Hospital Chaplain and Occupational Health may support the SOM with this. The Serious Untoward Incident (SUI) Policy should be initiated and details of the incident made available. The local Risk Management Team will undertake a Root Cause Analysis (RCA). 8

9 NB: a SOM independent of the incident must be involved in the RCA. The medical records should be reviewed by the SOM and a complete summary of the case recorded. It is important to note the names and PIN of all staff involved, particularly staff who do not normally work within the maternity unit, e.g. independent midwives, bank staff, agency staff. The case notes and all documentation should be completed, photocopied and secured at the first opportunity. The death should be reported to the Local Supervising Authority Midwifery Officer (LSAMO) as soon as practically possible, initially verbally followed by the completion of a maternal death Alert on the LS Database. The SOM and LSAMO will liaise with the Head of Midwifery concerning the setting up of a debriefing event. A checklist is supplied at appendix 3 to assist the coordinating SOM in meeting her responsibilities in relation to the maternal death. NB: the tasks outlined in this checklist will not necessarily be the responsibility of the coordinating SOM however; it is the SOMs responsibility to ensure that they have been carried out. 9

10 Appendix 1 - Local Contact Details TITLE NAME ADDRESS TELEPHONE NUMBER / FAX CEMH administrator Healthcare Improvement Scotland David Maxwell Healthcare Improvement Scotland Elliott House 8 10 Hillside Crescent Edinburgh EH7 5EA davidmaxwell@nhs.net (alternate contact is Leslie Marr see below) Reproductive Health Programme Manager Healthcare Improvement Leslie Marr Healthcare Improvement Scotland Elliott House 8 10 Hillside Crescent Edinburgh EH7 5EA Scotland LSAMO Mary Vance Assynt House Beechwood Park Inverness IV2 3BW leslie,marr@nhs.net maryvance@nhs.net Head of Midwifery Chief Executive Director of Nursing Director of Public Health 10

11 Appendix 2 - How to return maternal death information securely to the Confidential Enquiry into Maternal Health When sending any paperwork regarding maternal deaths which displays patient identifiable data it must be sent securely. Please place the paperwork in a suitable addressed envelope clearly marking it with MEDICAL IN CONFIDENCE. Place this envelope inside another addressed envelope with no confidentiality marking. This should then be posted using Royal Mail recorded delivery. Please remember to provide a return to name and address. When returning information to Healthcare Improvement Scotland, please use the following address: David Maxwell / Leslie Marr Reproductive Health Programme Healthcare Improvement Scotland Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA 11

12 Appendix 3 - Check List Name of Co-ordinating Supervisor: Yes Date 1. Has the Consultant/ medical staff on call' been contacted? Has the named Consultant been notified? Has the Consultant met the relatives? Has a 'follow-up' meeting been arranged? 2. Has a member of staff been identified to act as support to the family? Has religious support been requested and arranged for the family? 3. Has support been arranged for the staff involved in the maternal death? Has an SOM been called to provide support? Has debriefing been arranged for the staff involved in the maternal death? 4. Has all the documentation e.g. case notes and care-plan, been completed? 5. Have all records been photocopied and secured at the first opportunity? (Note the name of whoever does the photocopying) 6. Have the following people been notified of the maternal death? (if at night, the next day) Head of Midwifery LSA Midwifery Officer Medical Director and Clinical Director Chief Executive Named Community Midwife/Team Director of Nursing General/ CHP Manager GP Health Visitor Social Services (if live baby requires care and family support) Director of Public Health 7. Where a mother was booked in another area, have the following been notified? Consultant Head of Midwifery Supervisor of midwives 8. Has the mortuary been notified that a maternal death has occurred Has the Consultant informed the pathologist? Has information been given and permission been obtained from the next of kin to perform a post mortem? Has the Procurator Fiscal been informed? 9. Has a death certificate been completed? Where the death has been referred to the Procurator Fiscal, document this on the death certificate. 10. Where the baby is stillborn, has the stillbirth checklist been instigated? NB: If death occurs with baby in utero, this is not a stillbirth 11. Have the case notes and documentation been sent to the Procurator Fiscals Office? 12

13 12. Has an incident report been completed? 13. Has the co-ordinating supervisor of midwives ensured that the CEMH enquiry form is completed by the relevant midwives? NB: All staff should sign and date each contribution. 14. Has a SOM reviewed the maternity notes and completed a timeline of the case and identified any issues re midwifery practice Has a Root Cause Analysis been undertaken with SOM involvement Has n Alert been entered on the LSA Database under the section Maternal Death NB: where a field is not applicable please enter N/A in the relevant box 13

14 North of Scotland Local Supervising Authority Consortium