Maidstone and Tunbridge Wells NHS Trust
NHS / Health Body
Action Taken
The Trust detailed standard practice for checking placenta removal and monitoring blood loss after caesarean sections. They described actions to improve diagnosis and treatment of Postpartum Haemorrhage (PPH), including training, equipment, PPH boxes and proformas. Also described documentation training and audits for staff. (AI summary)
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Dear Mr Hatch
Re: Regulation 28 Report to Prevent Future Deaths following the inquest of Frances Cappuccini who died at Maidstone Hospital on 12 October 2012.
I am writing to respond to the concerns you raised during your investigation into the death of Frances Cappuccini, and to explain the actions that Maidstone and Tunbridge Wells NHS Trust has taken in order to address those concerns.
1) What action is taken to check and ensure no part of the placenta remains following a caesarean section delivery?
The standard practice for checking full removal of the placenta during a caesarean section delivery is as follows:
The Obstetrician performing the caesarean section inspects the uterine cavity and swabs it out prior to closure.
The Midwife inspects the placenta itself once removed – noting its appearance in the healthcare records – and determines if it looks intact. Each placenta is different in terms of shape and size, which makes this a challenging task, but if the Midwife has any concerns regarding the appearance of the placenta these are immediately escalated to the Obstetrician conducting the surgery for further investigation and exploration of the uterine cavity.
Once the caesarean section is completed, patients are initially monitored in Recovery before they are transferred to the Ward. Observations and vaginal blood loss are monitored closely and recorded in the healthcare records. Patients with significant blood loss (1500mls or above) remain on the Delivery Suite until their Haemoglobin (HB) is rechecked and observations remain stable. HB is a protein in red blood cells that carries oxygen throughout the body – by monitoring the level of HB we can quickly identify a lower level which might indicate complications that need to be investigated. By performing these checks
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
immediately after the surgery this affords patients prompt access to Obstetric and Anaesthetic input if needed.
We acknowledge, with regret, that this process was not successfully followed in Mrs Cappuccini’s case, however in the intervening years since this tragic incident all of our Obstetricians and Midwives have completed several rounds of annual training (theoretical and practical) to ensure that they are as qualified and experienced as possible to ensure better outcomes in the future.
Post-Partum haemorrhage (PPH) is a common occurrence in child birth, however due to the robustness of our processes and the additional training and support provided to staff, our outcomes are positive. Just three-weeks ago in our weekly Trust-wide newsletter I was able to praise the hard work of the entire team involved in providing care to a woman in our care which ultimately saved her life. The woman had suffered significant PPH after the caesarean section delivery of her baby but the volumes of blood loss were higher and over a more prolonged period that would be expected. The professionalism of the whole team involved in her care – from administrators, Porters, Haematology, Anaesthetics, Neonatal, Theatres, ITU, Obstetricians and Midwifery - meant that both mother and baby were stabilised and discharged home. We are a Trust that prides itself on learning, and so we are preparing a report on the case to be shared internally and externally as an example of good practice.
2) The protocol for the management of post-partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening again.
We ensure that all staff involved in providing care to patients who are at risk of suffering a Post-Partum haemorrhage (PPH) have read the Post-Partum Haemorrhage Protocol, and they sign a compliance slip to confirm this which is recorded within the department.
Although all staff have read the protocol, we find that the most effective way to ensure that protocols are followed is to imbed them in the day-to-day practice of our staff, so the required action becomes ‘second nature’.
The PROMPT method of training (Practical Obstetric Multi-Professional Training), which is a training programme run in maternity units across the country, incorporates the management of a range of Obstetric emergency situations with interactive drills and workshops to provide 'hands on' experience of practical skills and decision-making. The components of team working, including training for communication in an emergency, feature throughout the course. In the training sessions, which are attended by multidisciplinary groups of staff, each member of staff plays the role in the training scenario that they would play in a real situation.
PROMPT training supports the development of the technical skills required in an emergency and also the development of non-technical skills, such as effective communication, calling for help effectively, team working, making the best use of the resources available, and delegation. The training is modified
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
to target any trends that have been identified in incident analysis. The Anaesthetic scenarios that we use are varied from year to year so that they are relevant and tailored to the particular training needs identified. The scenarios we use include the types of problems that were encountered in the care of Mrs Cappuccini, and examples of the training scenarios are enclosed.
All Obstetricians, Midwives, Operating Theatre Practitioners and Anaesthetists who have a regular commitment to the Delivery Suite are required to attend mandatory PROMPT training annually. The relevant policies and guidelines are discussed as part of the training. Staff are reminded of any recent changes or updates to policies and guidelines and they are provided with further information about those changes. The attendance at training is recorded centrally and reviewed at annual appraisal and as staff approach the expiration date of their training, they and their managers receive a reminder via NHS email from our Learning and Development team to complete the training.
Within the Obstetric department, massive PPH is reviewed at the weekly risk review and staff receive regular feedback and guidance on best practice at monthly Clinical Governance sessions, through doctors’ newsletters and maternity risk updates.
In addition to the PROMPT training, the Trust also offers high fidelity simulation training for Obstetricians, Midwives and Operating Theatre Practitioners, and live emergency drills are run on the Delivery Suite when acuity allows. An example of this training is enclosed.
On 22 March 2017 we also ran a joint Clinical Governance session with Obstetrics and Anaesthesia and Mrs Cappuccini’s case (including inquest outcome and department reflections) was presented to a cross-section of staff – Consultants, Junior Doctors, Nurses, Midwives and Operating Theatre Practitioners. The session was well received and promoted much discussion and reflection, with suggestions for best practice shared across the two Directorates.
We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
3) Supervision - What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved?
All Anaesthetists have an electronic rota app on their phones and can identify who is the staff grade on for Labour Ward and who is the consultant covering.
The rota has a simple, easy to understand format which shows that during day time hours Monday to Friday the staff grades are supervised by the Consultant Anaesthetist covering the Labour Ward and out of hours by the Consultant Anaesthetist on call. There is a policy within the department that in the unlikely event that the consultant covering Labour Ward is not contactable then the junior staff are to phone an alternative consultant - this would be the intensivist on call, the Anaesthetist or intensivist covering Maidstone hospital and failing that, the Clinical Director.
All staff grade and trainee Anaesthetists understand that they are in supervised roles, as this is detailed within their job descriptions and in their induction packs. This information is also included within the induction packs for locum staff so they are aware of supervision arrangements and how to contact key personnel in an emergency.
4) What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist.
There is now a Consultant Anaesthetist who exclusively provides cover for the elective caesarean section list. This means that the Consultant Anaesthetist on duty for the Delivery Suite has no other duties and is free to attend emergencies. Consultants are on site between 8am-6pm and on call outside of these hours.
The Anaesthetic and Obstetric departments, as well as switchboard, have access to a real-time electronic rota for the Anaesthetic department. There is also a weekly paper rota kept on Delivery Suite, and consultants add their name and bleep number to the whiteboard in the Labour Ward handover room. Additionally, the rotas are emailed out weekly to all senior staff and Delivery Suite Band 7 Midwives.
The rota now also incorporates the informal terms for the on-call Consultant Anaesthetist at Tunbridge Wells Hospital (‘the Man in Blue') and at Maidstone Hospital (“the Man in Red”) and all staff identified on the rota carry a mobile telephone and can be contacted either directly or via the Trust switchboard.
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
I would also add that the PROMPT training that staff working in the Delivery Suite undergo, provides greater assurance that staff have the awareness and confidence to identify the situations in which assistance should be requested.
5) The inquest showed a number of examples of inadequate note keeping at the hospital – what actions have been taken to ensure this is not repeated in the future.
Documentation training underpins core training for nurses, doctors and allied health practitioners at all levels within the organisation. All staff are aware of the importance of clear, and contemporaneous record keeping and the balance that must be struck between this obligation and the immediate care and treatment to be provided to our patients.
All staff undergo annual training which includes aspects of documentation within their departments, as well as the Trust-wide mandatory Information Governance training. The Trust Legal Services department also runs an update training programme which delivers training at departmental Clinical Governance, to Foundation Year (FY) 1 and FY2 doctor training days, and as part of the mandatory clinical update training and the nurse leadership training programme.
We continually review the documentation to be completed in addition to noting in the healthcare records, to ensure they are easy to use in the highly-pressurised situations in which our staff work.
We also undertake regular clinical audits on documentation. These audits can be local to each department - based on the challenges identified through previous audits or incident investigations - as well as the formal national audits we are obliged to conduct.
I want to thank you for taking the time to bring your concerns to my attention, and I trust that this response is to your satisfaction.
Re: Regulation 28 Report to Prevent Future Deaths following the inquest of Frances Cappuccini who died at Maidstone Hospital on 12 October 2012.
I am writing to respond to the concerns you raised during your investigation into the death of Frances Cappuccini, and to explain the actions that Maidstone and Tunbridge Wells NHS Trust has taken in order to address those concerns.
1) What action is taken to check and ensure no part of the placenta remains following a caesarean section delivery?
The standard practice for checking full removal of the placenta during a caesarean section delivery is as follows:
The Obstetrician performing the caesarean section inspects the uterine cavity and swabs it out prior to closure.
The Midwife inspects the placenta itself once removed – noting its appearance in the healthcare records – and determines if it looks intact. Each placenta is different in terms of shape and size, which makes this a challenging task, but if the Midwife has any concerns regarding the appearance of the placenta these are immediately escalated to the Obstetrician conducting the surgery for further investigation and exploration of the uterine cavity.
Once the caesarean section is completed, patients are initially monitored in Recovery before they are transferred to the Ward. Observations and vaginal blood loss are monitored closely and recorded in the healthcare records. Patients with significant blood loss (1500mls or above) remain on the Delivery Suite until their Haemoglobin (HB) is rechecked and observations remain stable. HB is a protein in red blood cells that carries oxygen throughout the body – by monitoring the level of HB we can quickly identify a lower level which might indicate complications that need to be investigated. By performing these checks
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
immediately after the surgery this affords patients prompt access to Obstetric and Anaesthetic input if needed.
We acknowledge, with regret, that this process was not successfully followed in Mrs Cappuccini’s case, however in the intervening years since this tragic incident all of our Obstetricians and Midwives have completed several rounds of annual training (theoretical and practical) to ensure that they are as qualified and experienced as possible to ensure better outcomes in the future.
Post-Partum haemorrhage (PPH) is a common occurrence in child birth, however due to the robustness of our processes and the additional training and support provided to staff, our outcomes are positive. Just three-weeks ago in our weekly Trust-wide newsletter I was able to praise the hard work of the entire team involved in providing care to a woman in our care which ultimately saved her life. The woman had suffered significant PPH after the caesarean section delivery of her baby but the volumes of blood loss were higher and over a more prolonged period that would be expected. The professionalism of the whole team involved in her care – from administrators, Porters, Haematology, Anaesthetics, Neonatal, Theatres, ITU, Obstetricians and Midwifery - meant that both mother and baby were stabilised and discharged home. We are a Trust that prides itself on learning, and so we are preparing a report on the case to be shared internally and externally as an example of good practice.
2) The protocol for the management of post-partum haemorrhage was not followed by the medical staff. What procedures have been instigated to avoid this happening again.
We ensure that all staff involved in providing care to patients who are at risk of suffering a Post-Partum haemorrhage (PPH) have read the Post-Partum Haemorrhage Protocol, and they sign a compliance slip to confirm this which is recorded within the department.
Although all staff have read the protocol, we find that the most effective way to ensure that protocols are followed is to imbed them in the day-to-day practice of our staff, so the required action becomes ‘second nature’.
The PROMPT method of training (Practical Obstetric Multi-Professional Training), which is a training programme run in maternity units across the country, incorporates the management of a range of Obstetric emergency situations with interactive drills and workshops to provide 'hands on' experience of practical skills and decision-making. The components of team working, including training for communication in an emergency, feature throughout the course. In the training sessions, which are attended by multidisciplinary groups of staff, each member of staff plays the role in the training scenario that they would play in a real situation.
PROMPT training supports the development of the technical skills required in an emergency and also the development of non-technical skills, such as effective communication, calling for help effectively, team working, making the best use of the resources available, and delegation. The training is modified
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
to target any trends that have been identified in incident analysis. The Anaesthetic scenarios that we use are varied from year to year so that they are relevant and tailored to the particular training needs identified. The scenarios we use include the types of problems that were encountered in the care of Mrs Cappuccini, and examples of the training scenarios are enclosed.
All Obstetricians, Midwives, Operating Theatre Practitioners and Anaesthetists who have a regular commitment to the Delivery Suite are required to attend mandatory PROMPT training annually. The relevant policies and guidelines are discussed as part of the training. Staff are reminded of any recent changes or updates to policies and guidelines and they are provided with further information about those changes. The attendance at training is recorded centrally and reviewed at annual appraisal and as staff approach the expiration date of their training, they and their managers receive a reminder via NHS email from our Learning and Development team to complete the training.
Within the Obstetric department, massive PPH is reviewed at the weekly risk review and staff receive regular feedback and guidance on best practice at monthly Clinical Governance sessions, through doctors’ newsletters and maternity risk updates.
In addition to the PROMPT training, the Trust also offers high fidelity simulation training for Obstetricians, Midwives and Operating Theatre Practitioners, and live emergency drills are run on the Delivery Suite when acuity allows. An example of this training is enclosed.
On 22 March 2017 we also ran a joint Clinical Governance session with Obstetrics and Anaesthesia and Mrs Cappuccini’s case (including inquest outcome and department reflections) was presented to a cross-section of staff – Consultants, Junior Doctors, Nurses, Midwives and Operating Theatre Practitioners. The session was well received and promoted much discussion and reflection, with suggestions for best practice shared across the two Directorates.
We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
3) Supervision - What action has been taken to ensure that staff grade anaesthetists are supervised and that both the staff grade and supervisor are provided details of the respective identities of the parties involved?
All Anaesthetists have an electronic rota app on their phones and can identify who is the staff grade on for Labour Ward and who is the consultant covering.
The rota has a simple, easy to understand format which shows that during day time hours Monday to Friday the staff grades are supervised by the Consultant Anaesthetist covering the Labour Ward and out of hours by the Consultant Anaesthetist on call. There is a policy within the department that in the unlikely event that the consultant covering Labour Ward is not contactable then the junior staff are to phone an alternative consultant - this would be the intensivist on call, the Anaesthetist or intensivist covering Maidstone hospital and failing that, the Clinical Director.
All staff grade and trainee Anaesthetists understand that they are in supervised roles, as this is detailed within their job descriptions and in their induction packs. This information is also included within the induction packs for locum staff so they are aware of supervision arrangements and how to contact key personnel in an emergency.
4) What steps have been taken to avoid there being delays in a request for urgent help for an intensivist/anaesthetist.
There is now a Consultant Anaesthetist who exclusively provides cover for the elective caesarean section list. This means that the Consultant Anaesthetist on duty for the Delivery Suite has no other duties and is free to attend emergencies. Consultants are on site between 8am-6pm and on call outside of these hours.
The Anaesthetic and Obstetric departments, as well as switchboard, have access to a real-time electronic rota for the Anaesthetic department. There is also a weekly paper rota kept on Delivery Suite, and consultants add their name and bleep number to the whiteboard in the Labour Ward handover room. Additionally, the rotas are emailed out weekly to all senior staff and Delivery Suite Band 7 Midwives.
The rota now also incorporates the informal terms for the on-call Consultant Anaesthetist at Tunbridge Wells Hospital (‘the Man in Blue') and at Maidstone Hospital (“the Man in Red”) and all staff identified on the rota carry a mobile telephone and can be contacted either directly or via the Trust switchboard.
Chief Executive: Glenn Douglas Trust Headquarters: Maidstone Hospital, Hermitage Lane, Maidstone, Kent ME16 9QQ Telephone: 01622 729000/01892 823535 Fax: 01622 226416
I would also add that the PROMPT training that staff working in the Delivery Suite undergo, provides greater assurance that staff have the awareness and confidence to identify the situations in which assistance should be requested.
5) The inquest showed a number of examples of inadequate note keeping at the hospital – what actions have been taken to ensure this is not repeated in the future.
Documentation training underpins core training for nurses, doctors and allied health practitioners at all levels within the organisation. All staff are aware of the importance of clear, and contemporaneous record keeping and the balance that must be struck between this obligation and the immediate care and treatment to be provided to our patients.
All staff undergo annual training which includes aspects of documentation within their departments, as well as the Trust-wide mandatory Information Governance training. The Trust Legal Services department also runs an update training programme which delivers training at departmental Clinical Governance, to Foundation Year (FY) 1 and FY2 doctor training days, and as part of the mandatory clinical update training and the nurse leadership training programme.
We continually review the documentation to be completed in addition to noting in the healthcare records, to ensure they are easy to use in the highly-pressurised situations in which our staff work.
We also undertake regular clinical audits on documentation. These audits can be local to each department - based on the challenges identified through previous audits or incident investigations - as well as the formal national audits we are obliged to conduct.
I want to thank you for taking the time to bring your concerns to my attention, and I trust that this response is to your satisfaction.