Learning from maternal death investigations during the first wave of the COVID-19 pandemic

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.

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

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.

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

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’.

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

advice on potential alarming or warning symptoms

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

a discussion with the patient on the problem of uncertainty, inherent in all diagnoses particularly in the absence of definitive diagnostic tests

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

the likely time course of the illness and when to re-present to healthcare services

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

advice on accessing further medical care

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

follow-up, and the management of any tests ordered.

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

commencing urgent (category 1) caesarean section was delayed while staff donned PPE

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

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

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗

donning PPE prior to an ambulance crew entering a woman’s home, adding time before resuscitation could commence.

Source: Investigation report: Learning from maternal death investigations during the first wave of the COVID-19 pandemic ↗