At this point the team (obstetricians, anaesthetist and co-ordinating midwife) felt that delivery suite was busy and had many complex problems, but that they were managing it safely and effectively and did not consider escalating the situation.
Having reviewed the workload, it appears that the team had lost situational awareness and were only just managing. On reflection the team now feel that there would have been benefit in calling the on call consultant.
This may not have changed the overall outcome for the patient but it may have helped with the remainder of the work on delivery suite.
The amount and complexity of the work that night also impacted on the midwives in that Midwife 1 needed support in theatre which was unavailable until the Band 7 midwife came into theatre.
Calling out a second theatre team should have triggered the response of informing the on call consultant, this is an area of learning which will be taken forward as a recommendation of this report.
This report highlights a number of important areas and is typical of a good systems-based response.The team at the time were clearly happy with their situational awareness and implicitly seemed to have considered this. In retrospect, they could see they were deficient. Having reviewed the workload, it appears that the team had lost situational awareness and were only just managing.
On reflection, the team felt that there would have been benefit in calling the on-call consultant. This may not have changed the overall outcome for the patient but it may have helped with the remainder of the work on delivery suite.The report identifies the potential use of the on-call consultant to act in a role where he or she has oversight of the whole delivery suite in times of high activity.
Things you can do
A safety trigger should be created to make sure that the system does not rely on the team on delivery suite realising they have lost situational awareness; instead, there should be a fixed, forced trigger for the consultant to be contacted. Calling out a second theatre team could be trigger to the response of informing the on-call consultant to come and adopt a helicopter view whilst other team members are concentrating on tasks.