Serious 4D A baby unwell at delivery Despite many advances remain All women who are admitted to the maternity Actions later died. significant limitations with respect to the ward for observation in the antenatal period under way. usefulness of ultrasound to predict should be reviewed by an obstetric SMO on a actual or imminent fetal compromise in regular basis, ideally at least twice per late pregnancy. This meant that the week. The SMO must oversee care and degree of antenatal compromise in this formulate a coherent management plan and pregnancy was not recognised. where appropriate communicate this to colleagues. There was inadequate senior medical officer (SMO) supervision of care. No In all cases where there are suspected maternal one SMO took responsibility for making or fetal risk factors the decision for induction of a plan of management and labour should be reviewed by an obstetric communicating the history and that plan SMO. The current maternity unit of ‘Induction to the team on Birthing Suite. Labour’ guideline will require review and amendment to reflect this recommendation. There was no systematic obstetric SMO involvement in the induction process. SMOs should be involved at all steps of the More senior obstetric opinion may have induction process where such additional risk increased the awareness of risk and the factors are identified and a logical plan for priority for rapid delivery once events induction should be made by the obstetric SMO. unfolded. A classification system for caesarean section The current classification system for leaves no room for misinterpretation of caesarean section does not provide a urgency is required. The classification system sufficiently clear indication either of will indicate the need for a member of the urgency or of clinical indication. As a neonatal team experienced in advanced result, neonatal staff and some staff in resuscitation. Birthing Suite and Birthing Suite Theatre On introduction of this change, appropriate staff were not certain of the urgency education should take place. regarding delivery nor the reason for that urgency. This may have increased the Development of a for new neonatal RMOs interval from decision to delivery and on requesting anaesthetic support. may have compromised staffing at Improved processes for neonatal resuscitation baby’s resuscitation. training. Serious 6 Inpatient fall sustaining a The Clinical Board is providing a leadership role to progress broken hip. the vision of having zero harm from falls. All SAC 1 & 2 falls are
Serious 4D A baby unwell at delivery later died. Despite many advances remain significant limitations with respect to the usefulness of ultrasound to predict actual or imminent fetal compromise in late pregnancy. This meant that the degree of antenatal compromise in this pregnancy was not recognised. There was inadequate senior medical officer (SMO) supervision of care. No one SMO took responsibility for making a plan of management and communicating the history and that plan to the team on Birthing Suite. There was no systematic obstetric SMO involvement in the induction process. More senior obstetric opinion may have increased the awareness of risk and the priority for rapid delivery once events unfolded. The current classification system for caesarean section does not provide a sufficiently clear indication either of urgency or of clinical indication. As a result, neonatal staff and some staff in Birthing Suite and Birthing Suite Theatre were not certain of the urgency regarding delivery nor the reason for that urgency. This may have increased the interval from decision to delivery and may have compromised staffing at baby’s resuscitation. All women who are admitted to the maternity ward for observation in the antenatal period should be reviewed by an obstetric SMO on a regular basis, ideally at least twice per week. The SMO must oversee care and formulate a coherent management plan and where appropriate communicate this to colleagues. In all cases where there are suspected maternal or fetal risk factors the decision for induction of labour should be reviewed by an obstetric SMO. The current maternity unit ‘Induction of Labour’ guideline will require review and amendment to reflect this recommendation. SMOs should be involved at all steps of the induction process where such additional risk factors are identified and a logical plan for induction should be made by the obstetric SMO. A classification system for caesarean section leaves no room for misinterpretation of urgency is required. The classification system will indicate the need for a member of the neonatal team experienced in advanced resuscitation. On introduction of this change, appropriate staff education should take place. Development of a for new neonatal RMOs on requesting anaesthetic support. Improved processes for neonatal resuscitation training. Actions under way. Serious 6 Inpatient fall sustaining a broken hip. The Clinical Board is providing a leadership role to progress the vision of having zero harm from falls. All SAC 1 & 2 falls are
SSE_cases_2010_11_FINALv1.docx