West District Health Board www.westcoastdhb.org.nz Serious or Description of event Review findings Recommendations/actions Follow-up sentinel code Sentinel 4B Death of a baby following Review underway. Report awaited. emergency caesarean section. Serious 4B Mother transferred to Report completed. The patient had A comprehensive handover be provided to Christchurch by ambulance been medically cleared for ambulance appropriate CDHB staff for all maternity related following birth was suffering transfer without escort. While it transfers. To support the process for mothers from eclampsia on arrival. appears that a clear process for post delivery, a guideline be developed based assessment and transfer occurred in upon the current document for ‘Guidelines this instance, there are no written transfer of Maternity Care, Secondary – guidelines regarding transfer of Tertiary’, this to include guidance as to when a mothers post delivery, nor guidance midwife escort is appropriate. around when a midwife escort is appropriate.
West District Health Board www.westcoastdhb.org.nz Serious or sentinel code Description of event Review findings Recommendations/actions Follow-up Sentinel 4B Death of a baby following emergency caesarean section. Review underway. Report awaited. Serious 4B Mother transferred to Christchurch by ambulance following birth was suffering from eclampsia on arrival. Report completed. The patient had been medically cleared for ambulance transfer without escort. While it appears that a clear process for assessment and transfer occurred in this instance, there are no written guidelines regarding transfer of mothers post delivery, nor guidance around when a midwife escort is appropriate. A comprehensive handover be provided to appropriate CDHB staff for all maternity related transfers. To support the process for mothers post delivery, a guideline be developed based upon the current document ‘Guidelines for transfer of Maternity Care, Secondary – Tertiary’, this to include guidance as to when a midwife escort is appropriate.
SSE_cases_2010_11_FINALv1.docx