Source · HSSIB Patient Safety Investigation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
Published 15 April 2021
Launched 1 June 2020
Published
HSIB Legacy
Maternity
Coronavirus (COVID-19)
We have carried out a themed review of our maternal death investigations during the coronavirus (COVID-19) pandemic.
Summary
3 observations
8 learning prompts
Safety Observations
Observation 1
Observation
It may be beneficial if further work
is done to understand the increased risk of maternal death for women from Black, Asian and minority ethnic backgrounds and those with higher socio-economic deprivation.
Observation 2
Observation
It may be beneficial if the NHS
England and NHS Improvement communications toolkit for local maternity teams to improve communications with women from Black, Asian and minority ethnic backgrounds is implemented in all healthcare services for pregnant women.
Observation 3
Observation
It may be beneficial if written safety netting advice is developed for pregnant and postpartum women about COVID-19 and other common conditions, incorporating the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) recommendations.
Related safety recommendation
This review adds weight to the safety recommendation (number R/2020/095) made in the HSIB report ‘COVID-19 transmissionin hospitals: management of the risk – a prospective safety investigation’, that:
‘It is recommended that the Department of Health and Social Care, working with NHS England and NHS Improvement, Public Health England, and other partners as appropriate, develops a transparent process to co-ordinate the development, dissemination and implementation of national guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID-19’.
Learning Prompts
Prompt 1
Learning prompt
advice on potential alarming or warning symptoms
Prompt 2
Learning prompt
a discussion with the patient on the problem of uncertainty, inherent in all diagnoses particularly in the absence of definitive diagnostic tests
Prompt 3
Learning prompt
the likely time course of the illness and when to re-present to healthcare services
Prompt 4
Learning prompt
advice on accessing further medical care
Prompt 5
Learning prompt
follow-up, and the management of any tests ordered.
Prompt 6
Learning prompt
commencing urgent (category 1) caesarean section was delayed while staff donned PPE
Prompt 7
Learning prompt
delays due to the additional infection prevention control requirements, including donning and doffing PPE multiple times as a clinician moved between areas to obtain test results from equipment located on another ward during resuscitation
Prompt 8
Learning prompt
donning PPE prior to an ambulance crew entering a woman’s home, adding time before resuscitation could commence.