1. Safety and Quality in maternity care Denise Boulter Midwife Consultant Public Health Agency

2.  Florence Nightingale,  Notes on Nursing: What It Is, and What It Is Not  “The very first requirement in a hospital is that it should do the sick no harm.”

3. Safety and Quality Everyone's Responsibility Drive improvement by taking complaints / whistleblowing seriously Value Patient/family feedback: to address failings and improve performance Board members should walk the wards, engage with staff and talk to patients

4. Quality of care in maternity services Avoidable harm Reduce stillbirths, reduce babies born in poor condition, optimise outcomes Improve detection and management of fetal growth restriction Reduce maternal morbidity – post partum haemorrhage, 3/4 th degree tears

6.  To err is human  To cover up is unforgivable  To fail to learn is inexcusable The Message

7. HIQA Report “A positive safety culture includes open communication with patients, strong clinical leadership and professional accountability, effective multi-disciplinary team working, appropriate behaviour, evidence based practice, adherence to policies and guidelines and clinical audit”

8. Care of Savita Hallapanavar Primigravida at 17 weeks gestation Day 1: 09.35: self referral to gynae ward with lower bachache radiating to lower pelvic region and urinary frequency. Probable diagnosis? Actual diagnosis given- Symphysis pubis dysfunction Missed opportunity!!!!!

9. Day 1 continued 15:30-22:00  Re-attended ward with continuing symptoms  On examination membranes bulging and visible  Fetal heart heard and regular  Bloods reserved white cell count 16.9 What would you do? Diagnosis- impending pregnancy loss Admitted Bloods not reviewed by clinicians Missed opportunity!!!!

10. Day 2 00:30-06:30  SROM at 00:30 What would you do?  No observations recorded during this time  Early Warning Score not commenced  Prophylactic antibiotics not prescribed Missed opportunity!!!!!

11. Day 2 continued 08:20  Reviewed by consultant  Requested ultrasound scan  “await events” What would you do? No comprehensive plan of care was developed No mention of probable infection No mention of impact of SROM on probable infection Missed opportunity!!!!

12. Day 2-Day 3 15:25-06:00  Over this 15 hour period 3 recordings of low blood pressure and 2 of elevated heart rate were documented What does this indicate?  Clinical significance was not recognised by staff  Therefore clinical deterioration with a probable cause of infection was not recognised Missed opportunity!!!

13. Day 3 08:30  Consultant review  24 hours SROM  Antibiotics commenced 21 hours following  Deterioration in clinical observations not noted Missed opportunity!!!

14. Day 3 continued 14:45-20:00  3 recordings of an increased heart rate including 114 at 19:00 What would you do?  Staff failed to recognise this as significant Missed opportunity!!!

15. Day 3- Day 4 21:00-01:00  Patient complained of weakness  Doctor called- not immediately available What would you do?  Not escalated to another doctor Missed opportunity!!!

16. Day 4 04:15- 05:00  Patient had raised temperature, shivering and vomiting What would you do?  Given a blanket  No evidence these symptoms were recognised as indicative of sepsis Missed opportunity!!!

17. Day 4 continued 06:30- 07:50  Significant deterioration  Temperature and pulse elevated, blood pressure low  Feeling weak and unwell  Offensive vaginal discharge What would you do?  Reviewed by junior doctor- diagnosis of “chorioamnionitis with probable sepsis”  Bloods reserved  Intravenous antibiotics commenced  Discussed case  No change to management plan Missed opportunity!!

18. Day 4 continued 08:25  Reviewed by consultant as part of ward round  Pulse and temperature elevated  Further antibiotics prescribed  Results of tests noted as pending What would you do?  Nothing further noted Missed opportunity!!!

19. Day 4 continued 13:00 And finally!! Recognition!!  Consultant contacted by nursing staff  Diagnosis of septic shock made  Discussed case with consultant microbiologist  Review by anaesthetic staff  No HDU bed available, transferred to theatre for on-going high dependency care until bed available  Spontaneous delivery of fetus and placenta in theatre  Transferred to HDU at 16:45

20. Day 5- Day 8  Condition continued to deteriorate  Transferred to ICU  Cardiac arrest day 8 and despite resuscitation patient died

21. Would we have been better? We have help  Maternity early warning scores  Jump calling  Awareness of sepsis?  Serious Adverse Incident reporting  Learning letters  Shared learning  Similar case to this in ROI 4 years previously learning not taken on board

22. Our successes to date

23. No complacency  Need to encourage a reporting culture and remove blame culture  Continue to learn from SAI’s, complaints  Adopt learning from other areas e.g. Scotland

24. Blame doesn’t move the game on! A learning culture enhances team performance!

26. and finally……….any Questions? “Tell me and I forget, teach me and I may remember, involve me and I learn.” Benjamin Franklin Benjamin Franklin