Safety and Quality in maternity careDenise BoulterMidwife ConsultantPublic Health Agency

Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not

“The very first requirement in a hospital is that it should do the sick no harm.”

Safety and QualityEveryone's Responsibility

• Drive improvement by taking complaints / whistleblowing

seriously

• Value Patient/family feedback: to address failings and

improve performance

• Board members should walk the wards, engage with staff

and talk to patients

Quality of care in maternity servicesAvoidable harmReduce stillbirths, reduce babies born in poor condition, optimise outcomesImprove detection and management of fetal growth restrictionReduce maternal morbidity – post partum haemorrhage, 3/4th degree tears

To err is humanTo cover up is unforgivableTo fail to learn is inexcusable

The Message

HIQA Report“A positive safety culture includes open communication with patients, strong clinical leadership and professional accountability, effective multi-disciplinary team working, appropriate behaviour, evidence based practice, adherence to policies and guidelines and clinical audit”

Care of Savita HallapanavarPrimigravida at 17 weeks gestationDay 1:09.35: self referral to gynae ward with lower bachache radiating to lower pelvic region and urinary frequency.Probable diagnosis?Actual diagnosis given- Symphysis pubis dysfunctionMissed opportunity!!!!!

Day 1 continued 15:30-22:00 Re-attended ward with continuing symptoms On examination membranes bulging and visible Fetal heart heard and regular Bloods reserved white cell count 16.9What would you do?Diagnosis- impending pregnancy lossAdmitted Bloods not reviewed by cliniciansMissed opportunity!!!!

Day 2 00:30-06:30 SROM at 00:30What would you do? No observations recorded during this time Early Warning Score not commenced Prophylactic antibiotics not prescribed

Missed opportunity!!!!!

Day 2 continued 08:20 Reviewed by consultant Requested ultrasound scan “await events”What would you do?No comprehensive plan of care was developedNo mention of probable infectionNo mention of impact of SROM on probable infectionMissed opportunity!!!!

Day 2-Day 3 15:25-06:00 Over this 15 hour period 3 recordings of low

blood pressure and 2 of elevated heart rate were documented

What does this indicate? Clinical significance was not recognised by staff Therefore clinical deterioration with a probable

cause of infection was not recognisedMissed opportunity!!!

Day 3 08:30 Consultant review

24 hours SROM Antibiotics commenced 21 hours following Deterioration in clinical observations not

noted

Missed opportunity!!!

Day 3 continued 14:45-20:00 3 recordings of an increased heart rate

including 114 at 19:00What would you do? Staff failed to recognise this as

significant

Missed opportunity!!!

Day 3- Day 421:00-01:00 Patient complained of weakness Doctor called- not immediately available What would you do? Not escalated to another doctor

Missed opportunity!!!

Day 4 04:15- 05:00 Patient had raised temperature,

shivering and vomitingWhat would you do? Given a blanket No evidence these symptoms were

recognised as indicative of sepsisMissed opportunity!!!

Day 4 continued06:30- 07:50 Significant deterioration Temperature and pulse elevated, blood pressure low Feeling weak and unwell Offensive vaginal discharge

What would you do? Reviewed by junior doctor- diagnosis of “chorioamnionitis with

probable sepsis” Bloods reserved Intravenous antibiotics commenced Discussed case No change to management plan

Missed opportunity!!

Day 4 continued 08:25 Reviewed by consultant as part of ward

round Pulse and temperature elevated Further antibiotics prescribed Results of tests noted as pendingWhat would you do? Nothing further notedMissed opportunity!!!

Day 4 continued13:00And finally!! Recognition!! Consultant contacted by nursing staff Diagnosis of septic shock made Discussed case with consultant microbiologist Review by anaesthetic staff No HDU bed available, transferred to theatre for

on-going high dependency care until bed available Spontaneous delivery of fetus and placenta in

theatre Transferred to HDU at 16:45

Day 5- Day 8 Condition continued to deteriorate Transferred to ICU Cardiac arrest day 8 and despite

resuscitation patient died

Would we have been better?We have help Maternity early warning scores Jump calling Awareness of sepsis? Serious Adverse Incident reporting

Learning letters Shared learning

Similar case to this in ROI 4 years previously learning not taken on board

Our successes to date

No complacency Need to encourage a reporting culture

and remove blame culture Continue to learn from SAI’s, complaints Adopt learning from other areas e.g.

Scotland

Blame doesn’t move the game on!

A learning culture enhances team performance!

speak up, highlight concerns, share good practice

and finally……….any Questions?“Tell me and I forget, teach me and I may

remember, involve me and I learn.” Benjamin Franklin