1. Reporting on potentially avoidable deaths Lynn Sadler Epidemiologist PMMRC

2. AIMS To go beyond rates and descriptive data To inform quality improvement

3. METHODOLOGY Development of a data collection tool Use of the tool in the review process Audit and reporting of data

4. Development of a data collection tool Developed iteratively from previous tools for perinatal and maternal mortality Previous tools include combinations of: –Systems factors, including environment, technology, organisation and management –Personnel factors –Patient factors Definitions: –Contributory factors –Potential avoidability/preventability

5. The PMMRC Tool Developed for assessment of preventability in maternal and perinatal mortality Domains: –organisation or management –technology and equipment –the environment –personnel –barriers to access or engagement with care

6. Have organisational or management factors been identified? Including but not limited to: –Poor organisational arrangements of staff –Inadequate education and training –Lack of policies/protocols/guidelines –Inadequate numbers of staff –Poor access to senior clinical staff –Failure or delay in emergency response –Delay in procedure –Delayed access to test results or inaccurate results –Other, please state..

7. Have technology and equipment factors been identified? Including but not limited to: –Essential equipment not available –Lack of maintenance of equipment –Malfunction/failure of equipment –Failure/lack of information technology –Other, please state…

8. Have environmental factors been identified? Including but not limited to: –Geography eg long transfer –Building and design functionality limited clinical response –Other, please state…

9. Have factors relating to personnel been identified? Including but not limited to: –Knowledge and skills of staff were lacking –Delayed emergency response by staff –Failure to maintain competence –Communication between staff was inadequate –Failure to seek help/supervision –Failure to follow recommended best practice –Lack of recognition of complexity or seriousness of condition by caregiver –Other, please state…

10. Have barriers to accessing or engaging with care been identified? Including but not limited to: –Substance use –Family violence –Lack of recognition by the woman or family of the complexity or seriousness of condition –Maternal mental illness –Cultural barriers –Language barriers –Not eligible to access free care –Other, please state..

11. Was the death potentially avoidable? Yes No

12. Introduction of the tool for perinatal death Concept introduced in 2008 Training at PMMRC local coordinator workshop in March 2009 Local assessment at time of classification of cause of death Checked by national coordinator with feedback to local coordinator National coordinator visits ~5 DHB meetings per year

13. Data Quality 2009 Audit by national coordinator: –68 randomly selected perinatal deaths –Potentially avoidable perinatal death 19% by local assessment 31% at audit –2/48 from “no” to “yes” –6/7 from “not stated” to “yes”

14. Findings: Perinatal related deaths 2009 Perinatal related deaths n=720 Contributory factorsn% Yes16924 No46565 Not stated8211 Potentially avoidable9814 5th report PMMRC: Page 60

15. Findings: Perinatal related deaths 2009 StillbirthsNeonatal deaths n=401n=182 Contributory factorsn%n% Yes102256134 No2506210357 Not stated49121810 Potentially avoidable60153519 5th report PMMRC: Page 60

16. Findings: Perinatal related deaths 2009 Perinatal related deaths n=720 Contributory factorsn% Total16924 Organisational/management345 Technology and equipment61 Environment122 Personnel507 Barriers to access/engagement11115 5th report PMMRC: Page 62

17. Findings: Perinatal related deaths 2009 5th report PMMRC: Page 63

18. Absolute numbers of perinatal related deaths with contributory factors by PDC: 2009 5 th report PMMRC: Page 65

19. Conclusions In 2009, a tool for assessing contributory factors and potential avoidability of perinatal death was introduced. Utilises “local” review The findings are preliminary as the process becomes familiar

20. Conclusions Contributory factors were assessed as present in at least 24% of perinatal deaths, and 14% were potentially avoidable. Most common factors were barriers to access and/or engagement with care (15%), personnel factors (7%) and organisational/management factors (5%)

21. International comparison data South Australia 2008 (n=608) –“Independent audit” –44% contributory factors –No assessment of rate of potentially avoidable death Dutch perinatal audit project 2009 (n=228) –“Independent audit” –32% contributory factors (Substandard care factors) –9% potentially avoidable Rotterdam 2008 (n=137) –Regional audit –50% contributory factors –26% possible and likely avoidable

22. Implications Preliminary data Possible issues with using the tool: need for ongoing local support and education May result in an increase in rates of contributory factors and potential avoidability in next few years Recommendations arising from the data

23. Future directions Ongoing support and education in use of the tool Plan to compare local to independent review of perinatal deaths in assessment of contributory factors and potential avoidability Plan to use the tool for severe maternal morbidity review at Auckland Hospital How do we use the data obtained to lead quality improvement in maternity care…

24. Acknowledgements Local coordinators National coordinator – Vicki Masson PMMRC members