Serious 4B Core midwife did Documentation of the outcome of the Develop a package that clearly identifies the not see that she assessment, interpretation of the fetal requirements when assessing an LMC’s patient. This had full monitoring and nature of the discussion will be to each core midwife who will sign to responsibility for with the LMC was not of the required identify they have read, understood and will comply. the patient in the standard. Re-launch fetal monitoring protocol with staff. absence of the Internal perinatal review revealed that Lead Maternity Develop a telephone record to capture clinical data fetal compromise occurred within last Carer (LMC). This when requested to assess an independent midwife’s weeks of baby’s life. led to a patient. communication issue between core and independent midwife regarding fetal monitoring outcome. Baby was born dead two days later. Serious 4B Delay in Independent midwife did not recognise Introduce updated emergency flip chart, strategically transferring the significance of the bleed and placed. mother with escalation process was delayed. Education for nursing staff on emergency bleed from management. rural maternity unit to tertiary unit. Both mother and baby recovered well. Serious 4B Delay in treatment The major root cause of this incident is Ongoing vigilance by screening staff members when Completed. of woman with the database having a reporting failure. checking reports to ensure there are no other breast cancer. anomalies with other invitational processes. As a result of identifying these issues, the data manager has developed a new local Access failsafe report to prevent and mitigate the risk of similar incidents occurring/reoccurring in the future.
Serious 4B Core midwife did not see that she had full responsibility for the patient in the absence of the Lead Maternity Carer (LMC). This led to a communication issue between core and independent midwife regarding fetal monitoring outcome. Baby was born dead two days later. Documentation of the outcome of the assessment, interpretation of the fetal monitoring and nature of the discussion with the LMC was not of the required standard. Internal perinatal review revealed that fetal compromise occurred within last weeks of baby’s life. Develop a package that clearly identifies the requirements when assessing an LMC’s patient. This will be to each core midwife who will sign to identify they have read, understood and will comply. Re-launch fetal monitoring protocol with staff. Develop a telephone record to capture clinical data when requested to assess an independent midwife’s patient. Serious 4B Delay in transferring mother with bleed from rural maternity unit to tertiary unit. Both mother and baby recovered well. Independent midwife did not recognise the significance of the bleed and escalation process was delayed. Introduce updated emergency flip chart, strategically placed. Education for nursing staff on emergency management. Serious 4B Delay in treatment of woman with breast cancer. The major root cause of this incident is the database having a reporting failure. Ongoing vigilance by screening staff members when checking reports to ensure there are no other anomalies with other invitational processes. As a result of identifying these issues, the data manager has developed a new local Access failsafe report to prevent and mitigate the risk of similar incidents occurring/reoccurring in the future. Completed.