Below is one of the case studies written by contributors to the Each Baby Counts project.
Shared learning from a systematic and consistent method of multidisciplinary review of babies reported to ‘Each Baby Counts’ in Cheshire and Merseyside.
Ai-Wei Tang and Rita Arya, Warrington and Halton Hospitals NHS Foundation Trust
Devender Roberts, Liverpool Women’s Hospital NHS Foundation Trust
In an attempt to reduce stillbirths, the Special Interest Group at the Cheshire and Merseyside Maternity, Children and Young People Strategic Clinical Network (MC&YP SCN), has developed a process of systematically examining and performing an honest review of care provided to intrapartum stillbirths, babies with severe brain injury due to labour and early neonatal deaths.
Through a standardised method, the group aimed to be consistent and reduce bias in the review process, identify recurrent themes and risk factors as well as producing actions plans for these themes for shared learning in the region. All in an endeavour to reduce perinatal mortality and morbidity.
All maternity units in the region, including ‘One to One Midwives’, have agreed to report to MC&YP SCN all babies reported to ‘Each Baby Counts’. The MC&YP SCN has established a virtual stillbirth panel membership group consisting of at least one consultant obstetrician and midwife from each trust. When a case is reported, the MC&YP SCN coordinate a central regional review panel meeting consisting of a minimum of two external reviewers (one consultant obstetrician and one senior midwife) along with the internal reviewers. All review panels have a standardised method of analysing care by utilising the National Patient Safety Agency (NPSA) Intrapartum Toolkit: Proforma for review of intrapartum related perinatal deaths (v3), which identifies risk factors and areas for improvement, if relevant.
Since April 2015, the group have had 19 external review panels from 7 of the 9 providers. Examples of themes identified include improper documentation, failure to escalate events to senior members of staff, lack of situational awareness in labour ward and misinterpretation of cardiotocography. These have been disseminated for shared learning as posters or ‘lesson of the week’. As this has only recently been introduced, we are not able to assess if this process has impacted on perinatal mortality and morbidity.
With this process, the group have been able to consistently review all intrapartum stillbirths, cases of severe brain injury secondary to labour and early neonatal deaths in the region. The group plan to collate recurrent themes that contribute to these adverse events, and circulate them as regional documents for shared learning. They are also in process of developing further regional guidelines for standardising practice and reducing in variation in obstetric care between maternity units.
As this process appears to be effective in creating an organised review of serious adverse events, the group also plan to review unplanned caesarean hysterectomies and maternal deaths in the same manner.
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