Sharman Weir

I recommend: (a)That the Queen Mother's Hospital should identify a lead obstetric consultant to develop a system for the management of patients with pre-eclampsia and eclampsia. This should include protocol development and updating, and appropriate staff training. (b)That the training of all junior medical staff at the Queen Mother's Hospital should include their being taught (1) about the potential seriousness of seemingly mild symptoms and signs and the treacherous nature of pre-eclampsia, (2) the significance of both systolic and diastolic blood pressure readings in patients with pre-eclampsia or suspected pre-eclampsia, and (3) that written records should be made of both systolic and diastolic blood pressure readings in the hospital records of such patients to enable their significance to be monitored. (c)That a doctor of registrar grade or above should be advised on the day of admission of the admission of a patient admitted to the ante-natal ward with pre-eclampsia or suspected pre-eclampsia; (d)That a patient admitted to the ante-natal ward with pre-eclampsia or suspected preeclampsia should be seen by a consultant obstetrician within the working day following her admission in order to determine the immediate and subsequent management of that patient in detail; (e)That blood tests instructed in relation to patients with pre-eclampsia or suspected preeclampsia should be taken in accordance with such an instruction. (f)That there should be an opportunity for all junior staff to de-brief after a fatal outcome in relation to a patient in relation to whose care they have been involved.