01. Introduction & acknowledgements Dec 2014

Report
Launch meeting – RCOG 9th December 2014
Saving Lives,
Improving Mothers’ Care
Jenny Kurinczuk
National Lead – MBRRACE-UK
National Maternal, Newborn and Infant Clinical Outcome Review Programme
Saving Lives, Improving Mothers’ Care
• Anticipation & past anxiety
– Testament to the national collaborative effort in the
continuation of the UK tradition of national self-audit
and critical reflection to improve care for women
• Looking forward
– Learning lessons – putting them into practice and
ultimately improving care for mothers, babies and
families in the future
Mixed news
– Much good news
– BUT lessons to be learnt – improvements in care
to be made – much based on the implementation
of existing guidelines and evidence
– Each death is a personal tragedy for every family
– Between 2009 and 2012 - 321 women died
• The women who died gave birth to 235 infants of whom 173
survived
• The women who died left behind a further 408 surviving
children
• In total 581 motherless children remain
Today is a day of transition
• Today is the beginning of the end of a process
for us – the process of critical evaluation and
identifying what needs to be done for this report
• For you it is the beginning of the start of a
process – improvement based on the findings
• My personal challenge to you today: is to
identify one thing from the findings of this report
which you can immediately take back and
change in your organisation to improve the care
of women
Acknowledgements
MBRRACE-UK collaboration
Marian Knight (Maternal Lead)
Elizabeth Draper (Perinatal Lead)
David Field (Perinatal Lead)
Charlotte Bevan (Sands)
Peter Brocklehurst
Ron Gray
Sara Kenyon
Brad Manktelow
Jim Neilson
Lucy Smith
Maggie Redshaw
Janet Scott (Sands)
Judy Shakespeare
MBRRACE-UK team
Charlotte McClymont
Marketa Laube
Sarah Lawson
Peter Smith
Carl Marshall
Lucila Canas Bottos
Scott Redpath
Joanne Oakley
Oliver Hewer
Sally Arlidge
Anjali Shah
Temporary staff members
Acknowledgements
HQIP
MBRRACE-UK Assessors
Jenny Mooney
Lorna Pridmore
Tina Strack
105 individual clinicians:
Anaesthestists
Obstetricians
Midwives
General Practitioners
Psychiatrists
Intensivists
Pathologists
Physicians (cardiology, neurology
infectious diseases)
Obstetric physicians
Emergency Medicine Specialists
UKOSS/UKNeS researchers
Manisha Nair
Nudrat Noor
MDE Ireland
Edel Manning
Michael O’Hare
MBRRACE-UK Sepsis TEG
Ron Daniels
Nuala Lucas
Dharmintra Pasupathy
Shiranee Sriskandan
Acknowledgements
• 265 MBRRACE-UK Lead Maternity
reporters across all Trusts and Health
Boards in the UK with maternity services
• Also staff in Mental Health Trusts who
access notes
Acknowledgements
Office for National Statistics
Sue Dewane
Chris Coutes
Joanne Evans
Joanne Copsey
National Records of Scotland
Julie Ramsay
Mary McDonald
ISD, Scotland
Rachael Wood
Carole Morris
Susan Frame
Jim Chalmers
Health Improvement Scotland
Leslie Marr
Chris Lennox
Jan Warner
NIMACH, Northern Ireland
Heather Reid
Joanne Gluck
Malcolm Buchanan
UKOSS, NPEU
Melanie Workman
Maureen Frostick
Phil Peirsegaele
Anne Smith
Patsy Smith
Acknowledgements
MBRRACE-UK Independent Advisory Group
Catherine Calderwood (Chair)
Janice Allister
David Bogod
Zoe Boreland
Cath Broderick
Roch Cantwell
Richard Cooke
Andy Cole
Jaqueline Cornish
Philip Cox
Polly Ferguson
Roshan Fernando
Melissa Green
David James
Helen Dolk
Alan Fenton
Bryan Gill
Mervi Jokinen
Jim Livingston
Heather Mellows
Liz McDonald
Edward Morris
Heather Payne
Nim Subhendar
Michele Upton
Jason Waugh
David Williams
Acknowledgements
MBRRACE-UK PPI Stakeholders
MBRRACE-UK Stakeholders
Jane Abbott (Bliss)
Beverly Beech (AIMS)
Jenny Chambers (OC Support)
Jane Denton (MBF)
Jane Fisher (ARC)
Pauline Hull (EC.com)
Penny Kerry (Miscarriage Association)
Beckie Lang (Tommy’s)
Neal Long (Sands)
Sarah McMullen (NCT)
Jane Plumb (GBS Support)
Andrea Priest (Best Beginnings)
Gwynne Rayns (NSPCC)
Jean Simons (Lullaby Trust)
Cheryl Titherly (ARC)
Maureen Treadwell (BTA)
Carmel Bagness (RCN)
Patrick Cadigan (RCP)
Hilary Cass (RCPCH)
Paul Clyburn (OAA & RCA)
Sanjeev Deshpande (BAPM)
Denis Evans (NNA)
Roshan Fernando (OAA & RCA)
Jacque Gerrard (RCM)
Steve Gould (BRIPPA)
Diane Hulbert (CEM)
Sarah Johnson (RCOG)
Lucy McKillop (RCP)
Lisa Nandi (BAPM)
Lesley Page (RCM)
David Richmond (RCOG)
Jane Sandall (BMFMS)
Neil Sebire (RCPath)
Lorraine Tinker (RCN)
Acknowledgements
• Everyone involved in confidential enquiries in the
past from which we have been able to build and
innovate
• Gwyneth Lewis
– Led the five triennial reports of deaths from 1994 to
2008
– most recently “Saving Mothers’ Lives” (2006-2008)
• Marian Knight
– Maternal Programme Lead, MBRRACE-UK
Funding
– Healthcare Quality Improvement Partnership (HQIP) on
behalf of:
•
•
•
•
NHS England
NHS Wales
Health and Social care division of the Scottish government,
Northern Ireland Department of Health, Social Services and
Public Safety (DHSSPS),
• States of Jersey, Guernsey and the Isle of Man
– Budget, maternal element: £352,700 per year
– RCOG – financial sponsorship towards today’s meeting

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