Powys Teaching Local Health Board
Directorate: Women’s and Children’s
Author: Lewis, Owen, Revell / Title: Guidelines for reporting a Maternal Death
Code: PtHB/MAT06

Guidelines for Reporting a Maternal Death

Policy Code / Date / Version Number / Planned Review Date
PtLHB/MAT 006 / Jun 2009
Feb 2012 / 1st Issue
2nd Issue – Reviewed and minor changes from CMACE 2011 / August 2012
Feb 2015
Document Owner / Approved By / Date
Women’s and Children’s Directorate / Women’s and Children’s Directorate
Clinical Effectiveness Committee / 29/03/2012
16/04/2012
Document Type / Guidelines

Guidelines for Reporting a Maternal Death

Contents / Page
Validation Form / 3
Equality Assessment / 4
Relevant to / 5
Purpose / 5
Definitions / 5
Responsibilities / 5
Process / 5
References / 5
Appendices
CHECKLIST FOR REPORTING A MATERNAL DEATH / 8

For Reviewed / Updated Policies Only:

Relevant Changes – / Date
CMACE 2011 / 18/03/12

VALIDATION & RATIFICATION

Title: Guideline for reporting a maternal death
Authors: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife
Directorate: Women and Children’s
Reviewed/ Updated by: Marie Lewis Practice Development Midwife, Donna Owen – Lead Midwife North Powys, Denise Revell Integrated Midwife
Approved for submission by: Cate Langley Date: 14/02/12
Evidence Base
Are there national guidelines, policies, legislation or standards relating to this subject area?
If yes, please include below:
Centre for Maternal and Child Enquiries (2011): Saving Mothers’ Lives – Reviewing maternal deaths to make motherhood safer: 2006-2008. CMACE, London
If No, please provide information on the evidence/expert opinion upon which the policy has been based.
CONSULTATION
Please list the groups, specialists or individuals involved in the development & consultation process:
Name / Date
Powys Midwives / 18/03/12
Supervisor of Midwives – Powys / 18/03/12
Practice Development Midwife / 18/03/12
Lead Midwives & Head of Midwifery / 18/03/12
Health Visitors and School Nursing team / 18/03/12
Women’s and Children’s Directorate Departmental leads, Safeguarding team, Andrew Cresswell / 18/03/12
Please insert the name of the Directorate/ Departmental/Discipline Committee or Group that has approved this policy/procedure/guidelines/protocol
Name / Date
Women’s & Children’s Directorate / 29/03/12
Clinical Effectiveness / 16/04/12
Implications
Please state any training implications as a result of implementing the policy / procedure.
No Additional Training required implementing this guideline.
Please state any resource implications associated with the implementation.
No Additional Resources required to implement this guideline
  • Please state any other implications which may arise from the implementation of this policy/procedure. Nil

For Completion by Quality & Safety Unit
Checked by: / Date:
Submitted to CEC: / Date:

Equality Assessment Statement

Equality statement
No impact / Adverse / Differential / Positive / Comments
Age / X
Disability / X
Gender / X / Woman focused midwifery policy
Race / X
Religion/ Belief / x
Sexual Orientation / X
Welsh Language / X
Human Rights / X

Please complete the following table to state whether the following groups will be adversely, positively, differentially affected by the policy or that the policy will have no affect at all.

Risk Assessment

Are there any new or additional risks arising from the implementation of this policy?
None
Do you believe that they are adequately controlled?
N/A.

Relevant to:

Local guideline for all midwives working in Powys.

Purpose

Professionals who are involved in providing both primary and secondary care play an important role in participating in the on-going Confidential Enquiry into maternal deaths by firstly recognising that a maternal death has occurred and secondly by ensuring that the appropriate people have been notified.

Responsibilities

All midwives working within Powys hold a recognised midwifery qualification. No additional qualifications are required to carry out this policy. Midwives will be required to attend yearly obstetric emergency drills as part of their midwifery updates.

Monitoring

This policy will be monitored through clinical midwifery supervision, issues raised through training days and the Datix reporting system.

Process

Introduction:

The Confidential Enquiries into maternal deaths is a triennial report, which gives an overview of the numbers and causes of maternal death is in the United Kingdom. The collated and annonymised information shows where improvements in clinical practice or service provision may help to prevent future deaths. It is therefore important that all cases are notified promptly so that full information on each case is readily available.

A maternal death may occur in the community or in the neighbouring DistrictGeneralHospital. The Enquiry is started by the Regional Manager Centre for Maternal and Child Enquiries (CMACE) of the district in which the woman lived. The responsibility for notifying the CMACE that a maternal death has occurred should rest with either the Head of Midwifery or by a Consultant or General Practitioner treating the woman during her final illness, if the death occurs within one year following the end of her pregnancy. It does not matter if more than one professional notifies CMACE as case ascertainment is more important than duplication.

Definitions (CMACE 2011):

Maternal Death

The death of a woman while pregnant or within 42 days of termination of pregnancy, from anycause related to or aggravated by the pregnancy or its management,but not from accidental or incidental causes. This can be sub-divided into

  • Direct - Resulting from conditions or complications or their management that are unique to pregnancy, occurring during the antenatal, intrapartum or postpartum periods.
  • Indirect - Resulting from previously existing disease, or disease that develops during pregnancy not as the result of direct obstetric causes, but which were aggravated by physiological effects of pregnancy e.g. cardiac disease, diabetes.
  • Late -Death of awoman from Direct or Indirect causes more than 42 daysbut <1 completed year after the end of the pregnancy.

Actions:

  • Complete checklist (appendix 1)
  • When CMACE in the woman’s district of residence is informed of a maternal death the regional officer will initiate the confidential enquiry form. After completing initial details of the case the form will be passed back to the nominated coordinator for relevant professionals to complete the form.
  • In order to preserve anonymity NO photocopies of the Enquiry Form should be made at this time.
  • All cases of maternal death will be presented to the Clinical effectiveness/Risk Management Committee on an annual basis.

References:

Centre for Maternal and Child Enquiries (2011): Saving Mothers’ Lives – Reviewing maternal deaths to make motherhood safer: 2006-2008. CMACE, London

Appendix 1

CHECKLIST FOR REPORTING A MATERNAL DEATH

Action / Date and Time / Signature
Inform the following:-
  • Head of Midwifery/Supervisor of midwives
  • Women and Children’s Directorate Manager
  • LHB Chief Executive
  • Medical Director
  • Director of Nursing Services
  • Head of Clinical Governance/Risk Management
  • Relevant Heads of Service including Safeguarding (especially if there are other children in the family where concerns have been expressed Antenatally)

The case notes and ALL documentation should be completed, photocopied and given at the first opportunity to the nominated co-ordinator
Case notes and ALL documentation to be sent to the Coroner’s office if the coroner decides on a hearing
Report as a serious untoward incident (complete form and Datix)
Staff involved in the case to be offered support from peers, Supervisor of Midwives and Occupational Health
Notification of religion e.g. Priest, Vicar, Rabbi, Hospital Chaplain etc and Bereavement Services in line with family wishes

1