Guidelines for Assessing Avoidable Factors, Missed Opportunities and Sub-Standard Care in Confidential Enquiries into Maternal Deaths

Aims of assessment

1. To detect errors or omissions in the care of a pregnant woman who subsequently died such that these errors or omissions can be addressed (prevented in the future). It is not sufficient to say the care was sub-standard, one has to pinpoint what specifically in the care was sub-standard. Therefore, there must be a systematic approach to a death and a classification of avoidable factors, missed opportunities and sub-standard care such that useful information is obtained from each case and it can be fed back to the health workers and ultimately the community.
   
   
2. The classification must be logical, useable and information readily understandable for the "grass roots" health workers so that feedback can be effective.

Definition of sub-standard care

The United Kingdom has had a well established confidential enquiry into maternal deaths for many years. They had a system of analysing their maternal deaths and looking for "avoidable factors" and "missed opportunities" but have recently clarified their definitions and now talk about "substandard care". To quote from the Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1985-87, page xiv:

"Sub-standard care

The term substandard care has been used in this report to take into account not only failure in clinical care, but also some of the underlying factors which may have produced a low standard of care for the patient. This includes situations produced by the action of the woman herself, or her relatives, which may be outside the control of the clinicians. It also takes into account shortage of resources for staffing facilities; and administrative failure in the maternity services and the back-up facilities such as anaesthetic, radiological and pathology services. It is used in preference to the term "avoidable factors" which was used previously in the England and Wales Reports until 1979 and has also been used in the Scottish and Northern Ireland reports. This was sometimes misinterpreted in the past, and taken to mean that avoiding these factors would necessarily have prevented the death. "Sub-standard" in the context of the report means that the care that the patient received, or care that was made available to her, fell below the standard which the authors considered should have been offered to her in this triennium."

It is extremely important to understand that in assessing the case one is looking at the care in totality. This includes how were the basic things done, like routine antenatal care, as well as the event that led to the woman’s death.

The ultimate aim of the Confidential Enquiry into Maternal Deaths is to improve the standard and quality care of all pregnant women. A method for achieving this is to identify problems in the care of pregnant women and devising solutions for these problems. It is very difficult to analyse the standard of care of every pregnant woman, therefore a sample of women needs to be taken. The sample should be easily defined and representative of the whole population. There should not be too many cases to overwhelm the assessor’s, but enough to get meaningful results. The sample should also comprise of cases where the problems are most likely to be identified. Maternal deaths clearly meet all these criteria. Maternal deaths as the criteria for admission to the sample has the added advantage in that by monitoring the Maternal Mortality Rate, the success of the solutions can be measured.

This has been clearly demonstrated in relation to the care of the fetus and newborn. (Ref. PPIP etc.)

The basic philosophy rests on two assumptions:

1. The study of a "few" cases will reflect the care of all cases.
2. The problems that lead to a maternal death are the same as those of other pregnant women, but are just more severe, or the woman had an unlucky break.

There is compelling evidence that, provided there is a large enough sample, a few cases can represent the picture for the population. There is also strong evidence that the problems of care in maternal deaths are similar to those where pregnant women suffered acute severe morbidity but survived. (Ref. "Near Miss" Study).

Therefore, when analysing a maternal death all aspect of the care of the woman should be studied, because that will give a clearer picture of the standard and quality of care. In other words, not only factors leading directly to the death of the woman should be assessed and recorded.

Rationale of Classification system

The basic structure for detecting defects in health care is to analyse the woman and her environment, the administrative circumstances and the quality of health care individually. Information gained here can be fed back immediately to the relevant sections for action.

1. Patient related problems. (The woman and her environment)

Assessing avoidable factors or missed opportunities related to the woman and her environment is divided into three sections:

1. The first deals with issues relating to the woman herself, e.g. lack of knowledge etc.
2. The second relates to the influence the family has on the behaviour of the woman.
3. The third deals with the effect of the environment (community) where the woman lives on her behaviour. For example the availability of a telephone to call the ambulance service, or the attitude of the community towards the health services i.e. pressure by the community to consult a traditional healer or traditional birth attendant.

Clearly much of this information may not be available in patient’s case notes, but hopefully it will be discussed in the meeting where the Maternal Death Notification Form is filled in. Education regarding this aspect will need to take place. To this end this classification system will be included in the Guidelines for filling in the Maternal Death Notification Form. Special care must be taken not to victim blame, in this section. The full story tends to be complicated, and often circumstances dictate the behaviour and not neglect or desire to do damage on the side of the woman.

2. Administrative problems.

Administrative problems are easier to classify and the information easier to obtain. The problems are classified as:

1. Transport,
2. Barriers to access to health care facility,
3. Lack of accessibility
4. Lack of health care facilities
5. Lack of personnel
6. Lack of appropriately trained staff
7. Communication

Again these should be brought up at the discussion. Training will be needed.

3. Standard of health care

The assessment of the standard of care given to the woman by the health workers follows the same pattern for each section.

1. The standard of medical care is assessed during each of the following periods where applicable:

1. Antenatal care
2. Intrapartum care
3. Postpartum care
4. Emergency event/admission
5. Resuscitation
6. Anaesthesia

The assessment of the case notes is based on a systematic approach:

1. initial assessment,
2. problem identification,
3. management plan,
4. follow-up monitoring

(Except the resuscitation, which follows the ABCD protocol – airways, breathing, circulation, drugs).

This part concludes with a section for unprofessional conduct. Unfortunately, in a few cases, this may well be a major problem relating to the case, e.g. a doctor refusing to come and see a patient, or a nurse sleeping on duty.

4. Missing information

Finally, a death might not be able to be assessed because of lack of notes written by the health workers or the notes may be missing. There are codes for this. Valuable information is obtained here, by the very fact there are no notes indicates sub-standard care. Missing files indicates a major administrative problem.

Structure of the Assessor’s Form

The Assessor’s form is more of a checklist to ensure each aspect of care is evaluated. This is to ensure more uniformity in assessment and to allow for computerisation of the information. Tick only what is present. Space is available to allow for comments on each section.

The forms will be grouped into chapters (e.g. hypertensive diseases, haemorrhage,etc.), and the NCCEMD members will go through the cases again when compiling their recommendations. The comments will then be taken into consideration.

Spirit of the enquiry

When performing an assessment of a maternal death, the spirit that should pervade the enquiry is How could we do better? Care should be taken to avoid a defensive approach, epitimised by the question how can I protect myself or the hospital?

NOTE: The principle used when assessing the case notes is that where information is not documented, this implies it was not done, e.g. if the partogram was not filled in it was not used.

[Key quotes:

Regarding health workers:

It’s not what we do but what we don’t do that is the problem

It’s not what we know that is the problem, but what we know just ain’t so.

Must be aware of looking at natural occurrence rates (i.e. without intervention) rather than current rates. Current rates reflect the effect of care.

Lessons to be learnt from figures of the past.

Forgot lessons learnt.

Know what needs to be done, but lost the will to do something about it.]

28/02/98