Confidential regional enquiry into mature stillbirths and neonatal deaths—a multi-disciplinary peer panel perspective of the perinatal care of 238 deaths

K H Tan, M P Wyldes, R Settatree, T Mitchell
Singapore Medical Journal 1999, 40 (4): 251-5

AIM OF STUDY: To examine the sub-optimal factors relating to the care of stillbirths and neonatal deaths of birthweight 2.5 kg and above.

DESIGN: Regional confidential enquiry into stillbirths and neonatal deaths by multi-disciplinary panel.

METHODS: All 238 stillbirths and neonatal deaths of 2.5 kg and above in West Midlands Region, UK in the year 1991 were studied. Documents from each death were peer-reviewed by four assessors, one from each of the 4 disciplines, selected randomly from a pool of 24 senior obstetricians, paediatricians, general practitioners and midwives. Panel consensus for each death was reached to identify relevant factors related to sub-optimal care which might have prevented or would reasonably be expected to prevent an adverse outcome (Grades II & III sub-optimal care).

RESULTS: A total of 149 (62.7%) deaths were considered by the panel to have grade II or III factors. Of these, 151 (68.9%) were found in the antepartum period, 44 (20.1%) in the intrapartum period and 24 (11.0%) in the postpartum period. The majority (78.1%) of these factors involved clinical practice of care providers. Factors related to patient/family, equipment and staffing constituted 19.6%, 1.4% and 0.9% respectively. Important sub-optimal factors identified were lack of appreciation of antenatal and intrapartum risks factors (17.8%), the failure of proper interpretation and management of antepartum and intrapartum cardiotocography (12.8%), failure of adherence to accepted practice or standard care (12.8%), inadequate skills in neonatal resuscitation (4.5%) and adverse patient-related factors (19.6%).

CONCLUSION: Substantial scope exists for confidential multi-disciplinary peer review audit of current obstetric and neonatal care in the region in formulating a strategy to reduce perinatal mortality.

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