Dr Stephanie Smith1, Dr Charlotte Frise1, Dr Louise Page2, Ms Naomi Kelly2, Ms Clare Storer2
1Imperial College Healthcare NHS Trust , London, United Kingdom, 2Maternity and Newborn Safety Investigation (MNSI) programme, Care Quality Commission, London, United Kingdom
Biography:
Stephanie Smith is an Obstetrics and Gynaecology trainee in Kent, Surrey and Sussex, United Kingdom. She is currently completing a Clinical Fellowship in Obstetrics and Obstetric Medicine at Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust.
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 standardised, system focused methodology, into maternity events, including 237 maternal deaths.
Pulmonary embolism (PE) remains one of the leading causes of maternal deaths in the UK. Review of 18 deaths reported to MNSI related to PE was undertaken, to analyse for common themes of potentially contributory factors.
In 16 deaths communication issues were identified, such as:
Healthcare system relationships between:
– Different hospital departments in the same trust
– Different trusts
– Primary and secondary healthcare
These involved both written communication between teams (electronic and paper-based) and verbal communication, i.e. telephone contact, often made more difficult by the complexities of on-call arrangements.
For women and families:
– No pre-pregnancy counselling
– Education regarding the risks and symptoms of venous thromboembolism (VTE)
– Education and access to prophylactic or treatment dose low molecular weight heparin (LMWH) as indicated by their medical history
Key clinical areas highlighted included:
– Incorrect VTE score calculation: mainly with hyperemesis gravidarum and prolonged postnatal admission
– Medication errors: incorrect LMWH dosing, confusion surrounding intravenous heparin use and anti-Xa level monitoring
– Inconsistent access to prophylactic LMWH after a positive pregnancy test
– Incorrect use of D Dimer and modified Well’s score in pregnancy
We have developed a series of safety prompts based on the learning identified in this thematic review with the aim to improve communication, diagnosis of VTE, prescription of prophylactic LMWH in the first trimester and optimal management of VTE.
Keywords
Pulmonary embolism
Venous thromboembolism
Communication
References
https://www.mnsi.org.uk/
https://www.mnsi.org.uk/for-nhs/investigation-overview-for-nhs/
MBRRACE; Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21 October 2023 Marian Knight, Kathryn Bunch, Allison Felker, Roshni Patel, Rohit Kotnis, Sara Kenyon, Jennifer J Kurinczuk (Eds.)