Below is one of the case studies written by contributors to the Each Baby Counts project.
Northern England Maternity Clinical Network – Maternity Patient Safety Learning Network – “Development of a standardised regional approach to reviewing perinatal loss”
Karen Hooper, currently Patient Safety Midwife from County Durham and Darlington Foundation Trust, seconded to Northern England Maternity Clinical Network as Network Delivery Lead (Maternity), Each Baby Counts Lead Reporter and Expert Reviewer
Following the recommendations from Each Baby Counts report in June 2016, the Northern England Maternity Patient Safety Learning Network established a small task and finish group to look specifically at standardising processes for reviewing all perinatal losses.
The aims of the group were to establish a process in which all perinatal losses above 22 weeks gestation and occurring within 28 days of life had a review and that parents were involved in this process. The specific objectives were to standardise reviews and reduce variation, improve shared learning, include parents' perspective, include positive feedback and establish internal and external stakeholder involvement in reviews.
We felt that it was important to start the work towards standardisation whilst awaiting the roll-out of the national review tool. By establishing clear processes for review and family involvement, it was felt that once launched, the national tool would fit easily into these pathways.
We reviewed a variety of tools in use across the country used to review incidents, including the NPSA Intrapartum Toolkit and data requirements from both the Each Baby Counts and MBBRACE projects and identified a large amount of essential information which needed to be included in each review. However, the first draft was not user friendly. Retaining the same prompts, we modified the process into a presentation format which covers all of the relevant areas including maternal health, obstetric history, antenatal/intrapartum/postnatal events along with the ability to add or remove areas as necessary for the individual case. Using the NPSA themes and the assessment of care grid, the case is able to be graded by the review team, positive actions and lessons learned highlighted.
We are currently trialling the pro forma within my own Trust and have found that by completing the proforma as a presentation, it ensures an effective use of time as this forms the basis of case presentations at the monthly joint paediatric and obstetric perinatal mortality and morbidity meetings. We have found that this format changes the style of the meeting from one of presentation of information, to one of clinical review of cases and creates identification and ownership of actions arising.
In addition, we have commenced use of an individualised letter produced by SANDS to all families as part of the discharge process following perinatal loss. It includes a clear point of contact and options of how to ask any questions and be involved in the process.