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Guideline Written : Guideline and Education Group Date : 2005 Consultation process : Reviewed by the LSA Guideline and Education Group , East Midlands at 1 st and final draft stages . Comments invited from all Supervisors via the Contact Supervisor mechanism . Final draft reviewed by each LSA . Approved by : LSA Guideline and Education Group and Local Supervising Authority Midwifery Officers . Date : April 2006 Implementation date : April 2006 Review Date : October 2008 GUIDELINES FOR SUPERVISORS OF MIDWIVES IN THE EAST MIDLANDS MATERNAL DEATHS BACKGROUND The Confidential Enquiry into Maternal and Child Health ( previously CEMD ) is a triennial report , which provides on overview of the numbers and causes of maternal death in the United Kingdom . The collated and anonymised information shows where improvements in clinical practice or service provision may help to prevent future deaths . It is therefore important that all cases are notified promptly so that full information on each case is readily available . CEMD and the Confidential Enquiry into Stillbirths and Infant Deaths ( CESDI ) merged to form the Confidential Enquiry into Maternal and Child Health ( CEMACH ) on the 1 st April 2003. These enquiries form part of the National Institute of Clinical Excellence ( NICE ) work programme . It is statutory requirement that all health professionals provide information and participate in confidential enquiries and supervisors of midwives should ensure that other areas of the health service , such as Accident and Emergency units and Intensive Care are aware of this requirement and have a local process in place to report maternal deaths to the supervisor of midwives . The aims and objectives of the CEMACH Enquiry are to ; · Assess the main causes of and trends in maternal deaths , to identify any avoidable or substandard factors and to share these findings with all relevant health care professionals . · Improve the care that women receive and to reduce maternal mortality and morbidity rates . · To make recommendations on clinical care and service provision , including audit . · To suggest areas for future research and audit at a local and national level . · Produce a triennial report on behalf of CEMACH . DEFINITION OF A MATERNAL DEATH A Maternal Death is defined as any death , which occurs during or within one year of pregnancy , childbirth or abortion . This may be directly , indirectly or unrelated to the pregnancy . Direct - a death resulting from obstetric complications of the pregnant state ( pregnancy , labour and puerperuim ) , from interventions , omissions , incorrect treatment , or from a chain of events resulting from any of the above . Indirect - a death resulting from previous existing disease , or disease that developed during pregnancy and which was not due to direct obstetric cause , but which was aggravated by the physiological affects of pregnancy . Coincidental - a death that occurs from unrelated causes , which happens to occur in the pregnancy or puerperuim e. g . road traffic accident . Late - a death occurring between 42 days and one year after termination of pregnancy , miscarriage or delivery that are due to direct or indirect maternal causes . Pregnancy related deaths - a death occurring in women while pregnant or within 42 days of termination of pregnancy , irrespective of cause of death . All Maternal Deaths should be notified to the LSA Midwifery Officer on the following working day , using the specific proforma that accompanies this document . IMMEDIATE ACTIONS - DIRECT MATERNAL DEATH IN HOSPITAL The on call Supervisor of Midwives ( SoM(s ) ) and Consultant on call should be contacted and asked to attend . The following procedures outline the key responsibilities of the SoM . · The Consultant on call should be asked to attend . They should meet relatives as soon as possible . The women 's named Consultant should be informed when he/she is next on duty . · Support and information must be given to the immediate relatives/next of kin . Relatives may wish for religious or spiritual support . The Hospital chaplain may be contacted if appropriate . · Ensure that the Coroner has been notified . The Coroner 's office should be contacted ( cross reference your Local Policy for contact numbers ) . Out of hours a Coroner 's officer is available for emergencies ( 24 hour service ) . · The attending doctor cannot issue a death certificate without first referring for consideration by HM Coroner ( The mortuary department should be informed that a maternal death has occurred and to expect the patient without a death certificate ) . · Ensure appropriate provision is made for the baby ; consider social services for help and advice particularly if the couple are not married . · The senior clinician present should inform the family that it is not possible to issue a death certificate without consideration of post-mortem by the Coroner . · The Serious Untoward Incident Policy should be initiated and details of the incident made available ( if appropriate a Root Cause Analysis ( RCA ) will be undertaken by the Risk Management Team , a SoM must be involved in the RCA ( cross reference Reporting and Monitoring of Serious Adverse Events , Investigation of Incidents and the Role of the LSA ) ) . · The medical records should be reviewed and the SoM involved should complete a summary of the case . It is important to note the names of all staff involved , particularly those staff that do not normally work with the Maternity Unit ( i. e . Operation Department Assistant ( ODA ) or Operation Department Practitioner ( ODP ) , crash teams , attending anaesthetists etc . ) . · The case notes and all documentation should be completed , photocopied and secured at the first opportunity . There should be an early review of the records ; the midwifery care given should be reviewed by the SoM . · The SoM will ensure that appropriate support is offered to the staff involved . Personnel such as the staff counsellor or Hospital chaplain may support the SoM with this . · The SoM responsible for CEMACH and the Head of Midwifery ( HoM ) should be informed as soon as possible within normal working hours . Appendix 1 offers a checklist that may be used . IMMEDIATE ACTIONS - DIRECT MATERNAL DEATH IN PRIMARY CARE The woman 's Midwife is responsible for ensuring that a SoM is informed of any maternal death that comes to her attention in the Primary Care setting . The SoM will notify the HoM and the LSA and CEMACH . The GP should also have notified the Hospital if the woman has delivered or received care there . ROLE OF THE CEMACH SUPERVISOR OF MIDWIVES · The CEMACH SoM may need to be released from duties to undertake this role . · The CEMACH SoM should ensure that the local Trusts policies have been followed . · The death is reported as a Serious Untoward Incident ( SUI ) . This is usually undertaken via the Trusts Governance leads . · The death will be reported the Local Supervising Authority Midwifery Officer ( LSAMO ) as soon as practicably possible initially verbally followed by the maternal death proforma . · The SoM should ensure communication takes place within and across the primary and secondary sector , including the family GP , and any other statutory agency connected to the family . · The CEMACH SoM will arrange a debriefing of all staff involved . OTHER DEATHS ( INDIRECT , CONICIDENTAL AND LATE ) All other deaths should be dealt with on an individual basis as these may include , murder , suicide , road traffic collision , women with known terminal illness . COMPLETING THE ENQUIRY FORM The CEMACH SoM coordinating the enquiry should send a copy of the CEMACH notification form to the regional coordinator . On receipt of the booklet it is essential that the CEMACH SoM tracks the progress of the booklet internally and seeks to have the booklet returned to the regional coordinator at the earliest convenience . WHERE TO GO FOR FURTHER ADVICE South Yorkshire Jean Hawkins - LSA Midwifery Officer South Yorkshire Strategic Health Authority Fulwood House Old Fulwood Road Fulwood Sheffield S10 3TH Tel : 0114 2263352 Email : jean . H awkins@yorksandhumber . n hs . u k Trent Shirley Smith - LSA Midwifery Officer NHS East Midlands Octavia House Interchange Business Park Sandiacre Nottingham NG10 5QS Tel : 0115 9684557 Email : Shirley . s mith@eastmidlands . n hs . u k Maternal Enquiries Midwifery Assessors Ms Dotty Watkins Director of Nursing and Midwifery Royal Hallamshire Hospital Sheffield Tel 0114 2268429 Ms June Lovett Head of Midwifery Rotherham General Hospital Tel 01709 304255 REFERENCES AND BIBLIOGRAPHY CEMACH ( 2000-2002 ) ' Why Mothers Die . The sixth report of the confidential Enquiries into Maternal Deaths in the United Kingdom ' . www . C EMACH . o rg . u k LSA ( 2005 ) " Reporting and monitoring of serious adverse events , investigation of incidents and the role of the LSA " , Local Guideline APPENDIX 1 MATERNAL DEATH CHECKLIST 1 Contact SoM and Consultant on call . Clinical Manager/CEMACH SoM/Named Consultant should be notified when next on duty 2 The Coroner 's office should always be notified . A death certificate cannot be completed until consideration has been given by the Coroner ( Local Coroner 's advice available 24 hours per day on Tel : _____________ ( enter local number ) 3 Inform mortuary that a death has occurred and that a body will be sent without a death certificate . 4 Photocopy and secure medical notes at earliest opportunity . Make appropriate arrangements for admin support . 5 Social Services should also be notified if the family social circumstances are applicable , or if a live baby requires care and the family support . 6 The Trusts Chief Executive , the directorate Clinical Director , Risk Manager and the Strategic Health Authority Clinical Governance Lead , should be notified when next on duty . The SUI Policy should be instigated . 7 The CEMACH Regional Coordinator should be informed on the next working day , see local contact numbers . 8 The Regional Midwifery Assessor should be informed on the next working day , see local contact numbers . 9 Inform the woman 's GP , Midwife and Health Visitor as soon as possible on the next working day . 10 Inform LSA Midwifery Officer as soon as possible on the next working day and a brief report submitted with details of any supervision/practice/support issue as well as precise description of events . 11 If the woman has been admitted having been treated or booked in another area , the Senior Midwife and Consultant at that Hospital must be informed . 12 If the death of the baby has also occurred , the Local Confidential Enquiry into Stillbirths and Infant Death office must be notified . If the baby is born , dies or is dead , the procedure for CEMACH should be followed .