1. Why Did Mrs X Die? Understanding the Pathways to Maternal Death
From:

2. Understanding the “pathway to death”
Video
Why Did Mrs. X Die?

3. Short Exercise (10 minutes)
Turn to 1-2 people next to you
Discuss the video with the following in mind:
What was the direct cause of Mrs. X’s death
Were there any indirect causes?
What evidence did the review committees use to make changes in quality of care at the facility?
List 2 actions resulting from the analysis of Mrs. X’s death taken at the hospital and nationally)

4. Cycle of Data Collection, Reflection & Action
IDENTIFY THE PROBLEM
MONITOR ACTIONS & ADAPT IF REQUIRED
COLLECT DATA
IMPLEMENT RECOMMENDATIONS
PRESENT DATA IN USEFUL FORMATS
PROPOSE SOLUTIONS
DISCUSS DATA WITH RELEVANT PEOPLE
ANALYSE DATA

5. Cycle of Data Collection, Reflection & Action
EVIDENCE
IDENTIFY THE PROBLEM
MONITOR ACTION & ADAPT IF REQUIRED
COLLECT DATA
IMPLEMENT RECOMMENDATIONS
PRESENT DATA IN USEFUL FORMATS
ACTION
DISCUSS DATA WITH RELEVANT PEOPLE
PROPOSE SOLUTIONS
ANALYSE DATA
REVIEW