SLIDE 1
12 months data January –December 2016 Laura Bassett Risk Manager for Obstetrics & Gynaecology Cardiff & Vale University Health board.
SLIDE 2 In the UK 1 in every 200 births results in a
stillborn baby. The Welsh initiative to reduce stillbirths, resulting from an Assembly one day enquiry on Stillbirths (2013) set a primary driver to learn from the Perinatal review process both locally and nationally. The MBBRACE report 2015 also highlighted the need for a multidisciplinary review of all of these cases to help identify the cause of stillbirth.
Locally there was no in-depth analysis and no
- verall review of care was in place apart from an
initial review within the clinical risk forum.
SLIDE 3
A local review process that would identify themes
and causative factors for learning and future quality improvement.
Prior to each meeting a full case review of the
woman’s care from the time she accesses our service until the time of her discharge is prepared with all investigations undertaken.
The forum focuses on assessing the quality of
care received, identifying any points for learning and improvement and for feedback to the family and the staff involved.
The findings are fed back to the family as part of
the postnatal appointment with an Obstetrician and bereavement midwife; this ensures that all information is given at one point in time.
SLIDE 4 Purp
rpose
ting ng
To present a case review of all Fetal losses which
- ccur at ≥ 22 weeks gestation (All intra partum IUD’s
will be discussed at Clinical Risk meeting and actions noted at this meeting).
To identify appropriate actions if any further
investigation is required
To monitor progress of all cases under investigation
- r awaiting further results
To present final pathology reports and governance
investigations as a feedback and learning mechanism to staff involved
To provide sign off process for investigation of cases
SLIDE 5 MDT Senior midwife Obstetrician Consultant midwife Bereavement midwife Risk manager Pathologist SANDS representative Supervisor of midwives All Wales Perinatal Survey member Open for other staff members to attend.
Meetings take place monthly.
SLIDE 6 Review of all cases with the exception of MTOP’s Ongoing action plan for monitoring Feedback mechanism for staff to enable closure
Following discussion at the review forum,
learning outcomes and causation are agreed and identified and the decision is made if further governance investigation is necessary along with a plan of care for any subsequent pregnancy.
There is a joint focus in reducing Stillbirth
through implementation of quality management goals identified though learning and outcomes.
SLIDE 7
SLIDE 8
12Months Data January – December 2016
Month of stillbirth Gestation Growth Ethnicity Smoker Investigations BMI Age Parity Placental Histology Post-mortem uptake Reason/ causative factor MBBRACE quality of care criteria
SLIDE 9
1 2 3 4 5 6 7 8 9
SLIDE 10
5 8 4 10 6 3 1 1 3 1 2 4 6 8 10 12 Number
SLIDE 11
Retrospectively plotted on customised growth
charts
1st 6 months 50 % under 10th centile
SLIDE 12
5 10 15 20 25 30 35 40
Number ber
Number
SLIDE 13
Smoker 5 Non-smoker 17
SLIDE 14
2 cases Root Cause Analysis Cases reviewed by supervisor of Midwives
SLIDE 15
BMI
<20 20-25 25-30 30-35 >35
SLIDE 16
2 4 6 8 10 12 14 <20 20-25 25-30 30-35 35-40 40-45
Age
Age
SLIDE 17
Number ber
Primip Multip
SLIDE 18
Number ber
Placenta No Placenta
SLIDE 19
Number ber
Full External None
SLIDE 20 1 2 3 4 5 6 7 8
A851 - Unknown despite… A830- Unknown no autopsy A854- Unknown - unxplained A800 - Unknown no autopsy A831 - Unknown A099- Infection A714- Maternal Hypertension A791- Maternal trauma A644 - Placental Infarcts and… A680- Placental A651- Placental diabetes A637- Placental infection A681- Small placenta <2.5 A632- Placental abruption A673-Placental TTT syndrome A725- Uterine rupture A111- Extreme prematurity
SLIDE 21
- Documentation of condition of
baby
- Customised growth charts -
weight centiles
- Post mortem rates
- Gestation on histology forms
- Reduced fetal movements
- Interpreters
