Dr Emily Barrow2,1, Dr Charlotte Frise1, Miss Chandrima Biswas1, Katherine Hawes1, Kirsty MacLennan1, Gemma McIntyre1, Kate Palmer1, Sharon Perkins1, Miss Louise Page1
1Maternity and Newborn Safety Investigations (MNSI) programme, Care Quality Commission, London, UK, 2Chelsea and Westminster NHS Trust, London, UK
Biography:
Emily Barrow is a senior Obstetrics & Gynaecology trainee in North West London and is undertaking advanced training in Obstetric Medicine. She has a particular interest in patient safety and holds a PhD from Imperial College London focussing on the patient conceptualisation of patient safety.
Abstract:
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardized, system focused methodology, into maternity events, including 237 maternal deaths.
The 2020 MBRRACE-UK Report identified an increase in Sudden Unexpected Death in Epilepsy (SUDEP) and made recommendations for care standards.
Methods: We undertook a deductive, system focused, thematic analysis of 7 MNSI reports from maternal deaths from SUDEP between 2020-23, with an aim to add to the learning highlighted by MBRRACE-UK. The Systems Engineering for Patient Safety (SEIPS) model was used as a framework for initial coding.
Themes: Delivery of individualised specialist multidisciplinary care:
• Evidence that providers attempted to care for complex women within linear care pathways.
• Limited recognition of cumulative risk factors and holistic oversight of care needed.
Communication across multiple providers:
• Often no process for communication between different care providers.
• Limited information sharing, and multiple forms of paper and electronic documentation, leading to omissions including assessment of symptoms, medication compliance and neurology review.
Communication with healthcare professionals:
• Not easy for women to engage with care due to their individual social complexity/vulnerability, plus the complexity of the clinical system and care pathway.
• Even once engaged, there was evidence of inadequate education to women about important aspects including SUDEP.
Conclusion: Epilepsy care in pregnancy is complex and is optimised when delivered in a bespoke, flexible way informed by individual risk factors. Essential to this is collaborative working, between care providers and with women; shared access to information and the allocation of a lead professional with holistic oversight would support women to easily engage with their care. Care pathways would benefit from being supported by IT systems and the use of a shared care toolkit.
Keywords
Maternal death, Sudden expected death in epilepsy, Patient safety
References
Maternity & Newborn Safety Investigations. Home: The Maternity & Newborn Safety Investigations Programme [Online]; 2024 [Accessed 24 May 2024]. Available from: https://www.mnsi.org.uk.
Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2020.
Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013; 56(11):1669-86. doi:10.1080/00140139.2013.838643.