1. Lessons from a critical review of stillbirths? Malcolm Griffiths

2. Avoiding avoidable stillbirths Malcolm Griffiths Defining the unavoidable (lessons from an audit of stillbirths at L&D)

3. Background

5. CEMACH Data 2004 (E&W&NI)

7. SB rates 20002001200220032004 E&W NI 5.4 5.75.85.7 L&D8.9

8. Aims of the project Reduce the number of stillbirths to women resident in Luton/South Bedfordshire or those delivering at Luton & Dunstable Hospital By reducing avoidable stillbirths

9. Methodology Retrospective audit Critical incident review of each case by a multidisciplinary panel Open non-punitive discussion Classification of avoidable/non-avoidable Further review of common issues

10. Contributors Kathy Waller Helen Lucas Katie Chilton Eleanor Mirzaians Tracey Scivier Martina McIntyre Sandra White Hilary Hemming Sue Jalali HV Stephen Ramsden Malcolm Griffiths

11. Topics Retrospective Audit (Sandra White) Critical analysis of cases Risk factors Avoidability Issues Birthweight study Areas for improvement/action As we go along! Reprise!

12. Retrospective data Massive amounts of data Each stillbirth told its own story More common in primips Many of the women had had multiple attendances Much higher rates by Ethnic origin Practice Electoral wards

15. Avoidable Stillbirths More appropriate actions by clinical staff likely to have altered outcome More appropriate actions by mother or family likely to have altered outcome

17. More appropriate actions by clinical staff likely to have altered outcome Failure to consider induction of labour in high risk case (raised BP) Failure to comply with current policy (regarding fetal monitoring) where patient declined induction of labour Failure to recognise non-reassuring CTG

18. More appropriate actions by clinical staff likely to have altered outcome Failure to continue intensive fetal monitoring (IUGR – failed IOL – no further monitoring) Failure of GP to mention recent treatment for diabetes in referral letter

19. More appropriate actions by clinical staff likely to have altered outcome Failure to consider induction of labour in high risk case (raised BP) Feedback to clinician

20. More appropriate actions by clinical staff likely to have altered outcome Failure to comply with current policy (regarding fetal monitoring) where patient declined induction of labour Feedback to clinician Emphasising policy Empowering other staff to intervene

21. More appropriate actions by clinical staff likely to have altered outcome Failure to recognise non-reassuring CTG Feedback to clinician Increased training Emphasising policy Empowering other staff to intervene

22. More appropriate actions by clinical staff likely to have altered outcome Failure to continue intensive fetal monitoring (IUGR – failed IOL – no further monitoring) Feedback to clinician

23. More appropriate actions by clinical staff likely to have altered outcome Failure of GP to mention recent treatment for diabetes in referral letter Feedback to clinician

24. More appropriate actions by patient or family likely to have altered outcome Late booking – failure to receive anti-HIV therapy Delay in seeking help (decreased movements & APH) Refused appropriate induction of labour Delay in seeking help (APH)

25. More appropriate actions by patient and staff likely to have altered outcome Patient being followed up in DAU due to be reviewed in ANC - DNA

26. More appropriate actions by patient and staff likely to have altered outcome Meeting with members of the community Access to minority language link- workers by mobile phone Specialist HIV midwife Policy for chasing DNAs

27. “Unavoidable” Missed IUGR Missed IUGR in twins Missed diagnosis of “diabetes”

28. “Unavoidable” Missed IUGR Customised Growth Charts pilot Customised Growth Charts RCT Possible need for work with ultrasonographers

29. “Unavoidable” Missed IUGR in twins Review evidence for more frequent scans Review policies in other units Consider greater use of SFH charts

30. “Unavoidable” Missed diagnosis of “diabetes” Ask NICE to consider merits of screening for gestational diabetes Local review – possible selective screening

31. Birthweights Are “unexplained” stillbirths missed intra-uterine growth retardation (IUGR)?

34. Feedback to clinician Increased training Emphasising policies Empowering other staff to intervene Meeting with members of the community Access to minority language link-workers by mobile phone Specialist HIV midwife Policy for chasing DNAs Reprise!

35. Integration of community midwifery and health visiting Improve access of ethnic minority women to service Expected HV involvement would be welcome by bereaved families and would allow late feedback – not so! And also!

36. Lessons for others The critical incident review approach is useful and could be used in other areas (operative deaths, ITU deaths, readmissions) But needs Manageable numbers Multidisciplinary input Openness & Strict approach Enthusiasm & Ownership “Nagging voice”

37. Aims of the project No proof yet that we have achieved our aim  Reduce the number of stillbirths to women resident in Luton/South Bedfordshire or those delivering at Luton & Dunstable Hospital  By reducing avoidable stillbirths  But we are hopeful

38. Gestation specific birth weight centiles From January 2005 onwards, CEMACH has collected adequate information to allow the application of appropriate gestation-specific birth weight centiles to stillbirths and neonatal deaths. This will enable us to estimate the number of deaths that are of babies who are small for gestational age. This, coupled with a further question on evidence of fetal growth restriction, will allow some exploration of the association between growth restriction and stillbirth and neonatal death at a national level.