November 8, 2021

HSIB reports – Maternal death: Learning from maternal death investigations during the first wave of the COVID-19 pandemic

Funded by the NHS, The Healthcare Safety Investigation Branch (HISB) is an independent body who investigate circumstances where a mother or her baby has suffered an adverse event during pregnancy and/or childbirth. HSIB have released a collection of reports, the “Maternity National Learning Reports”, regarding maternity units, expectant mothers and newborn babies. These reports also include recommendations to improve patient care and safety.

The fourth report in the series entitled “Maternal death: Learning from maternal death investigations during the first wave of the COVID-19 pandemic” investigates the tragic deaths which occurred during the first wave of the Covid-19 pandemic amongst antenatal, perinatal, and postnatal women. These deaths were in a time where there were unprecedented factors – the increased use of PPE, remote consultations, restriction of visitors and ultrasounds, but to name a few. At this time, pregnant women were also deemed to be clinically vulnerable, although most pregnant women in the third trimester and postnatally had good outcomes from Covid-19 infection and the transmission to newborn babies was not common. The report by the HSIB found common themes from their investigation:-

- While the rate of pregnant women being admitted to critical care was at a similar rate to the general population, at 10%, further investigation found some clear disparities. 8 out of the 19 women whose deaths were investigated by HSIB were black, Asian or another ethnic minority. This is a rate of 42% compared to the 13.9% of the population that BAME women make up. In addition to racial disparities, it was further noted that 15 of the 19 women suffered from some form of pre-existing medical condition and that 12 of the 19 women came from the 4 most deprived areas in England as ranked by the Index of Material Deprivation. HSIB has advised that further investigations will need to take place to understand why a disproportionate number of BAME women and women from areas of socioeconomic deprivation died during this period. They have also recommended that an NHS Improvement Communications toolkit should be distributed to all healthcare services for pregnant women to improve communications with ethnic minority groups.

- Concerns were raised regarding maternal collapse at home by 14 of the 19 families of the deceased. 3 of these women died at home despite the efforts of attending medical professionals. In addition to collapse at home, HSIB also noted that families felt distressed by the fact that these women were alone with no support from their families, and therefore had nobody there to advocate for them on their behalf.

- The unprecedented demand for advice from healthcare services during the pandemic. Rates of calls to 111 more than doubled in March 2020 with patients reporting waiting over half an hour and then abandoning calls due to the length of time it has taken to get in contact with a medical professional. These delays have resulted in cases of no contact and no medical guidance, therefore leading to missed/late diagnosis.

- Public Health England released a slogan during the COVID-19 pandemic to: “Stay at home. Protect the NHS. Save lives” and while this was aimed at slowing the spread of the virus, it also led to pregnant women putting off going to hospital at a time when they needed to out of fear of contracting the virus. This delayed/nonattendance was a contributing factor into the death of some mothers. Further to this, women were also self-discharging from hospital at an increased rate out of fear of putting themselves and their baby at risk. MBRRACEUK have recommended that there should be advice distributed nationally regarding COVID guidelines, including information on how and when to contact local maternity units and professionals; HSIB have agreed and added that this should be in a written communication for both pregnant and postpartum mothers.

- Due to COVID-19 being a novel (unknown) virus, the guidance in healthcare settings changed rapidly as we learnt more about it. However, with such a large amount of information changing at such speed, it became hard for staff to keep up with guidance. Between 01/03/20 and 31/05/20, infection control protocol changed 21 times. Not all information was spread to staff in an effective way, resulting in instances where not all guidelines were followed. An example of this being investigated by HSIB is when hourly oxygen saturation and respiratory checks during labour were not performed due to not all staff being aware of this new guideline. The recommendation has been made that the Department for Health and Social Care and the NHS produce a clear process regarding the distribution of new guidance to minimise risk.

- The use of early warning scores was not always accurate in detecting deterioration of condition. It has been found that while there is specific nationally agreed early warning score system for maternity, the NEWS2 (National Early Warning System 2) appeared to have been the most used system in the reports. Additionally, there are no universal trigger points for escalation of care. Findings show that some women’s respiratory scores went up and weren’t deemed a cause for concern as causes other than COVID-19 did not appear to be considered.

- The change in PPE requirements caused communication difficulties with both staff and patients having to repeat themselves to be heard and understood. This also caused staff to ask for clarification of instructions, with the hospital setting becoming excessively noisy due to masks muffling speech. Further to the limits put on communication, PPE was not always kept in a convenient location – whereas pre-pandemic medical staff could move between patients a lot more freely, there were delays between treatments as staff had to put on and take off PPE between each patient. This also caused delays in emergency treatment such as category 1 c sections. Staff also reported issues of masks causing glasses to fog up and visors fogging up putting limits of medical staff’s physical ability to see.

- The stress of working in the healthcare sector during the pandemic has had a direct impact on clinical staff’s ability to effectively treat patients and provide a high standard of care – both inside and outside of maternity units. Staff have described feeling stressed and in states of distress. High stress levels have been noted as causing narrow vision when treating patients, focusing on one task at a time which can have a detrimental effect when missing other symptoms of collapse. Absentminded and forgetfulness were also been described by medical staff working through the pandemic, and the already stressed workforce suffering from communication issues. The excess stress had a direct impact of staffing levels which were already reduced to help with infection control as there was a rise in staff taking sick leave due to excess stress.

- Factors causing difficulty in making diagnosis and deciding on treatment methods during the pandemic had a direct impact on the deaths. Furthermore, healthcare staff were told to reduce contact with patients who didn’t urgently need to seek specialist care. This meant that patients were often assessed by staff who were not clinical obstetricians and via telephone calls rather than face to face. This left women without full clinical assessments, and therefore some crucial symptoms were missed that ultimately led to maternal death.

The maternal deaths reported are very, very sad indeed, particularly it appears where many could have been avoided with good quality medical care.

We are pleased to see that recommendations are being made regarding the safety of both mother and child during maternity care. We at RWK Goodman warmly welcome any changes that can be made to improve patient safety and hope that all maternity services take these recommendations into account to ensure that patient care and safety is that of a high standard through COVID times and beyond.

RWK Goodman have a clinical negligence team with specialism in birth injuries. If you would like further information on the HSIB reports and birth injury claims, you can click here to read our HSIB guide or contact us for further, personalised legal advice.

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