Irish inquiry reports on pregnancy loss services: recommendations on management of information and maternity services governance

Irish inquiry reports on pregnancy loss services: recommendations on management of information and maternity services governance

Authors: Änne Helps (1,2,3), Sara Leitao (2), Laura O’Byrne (1), Richard Greene (2), Keelin O’Donoghue (1,3)

(1) Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Ireland; (2) National Perinatal Epidemiology Centre (NPEC), University College Cork, Ireland; (3) The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Ireland

Background
External inquiries are carried out following specific adverse maternal events and aim to identify issues in the maternity care provided to pregnant women and make recommendations to improve standards of care. This study, presents the analysis of two of the domains identified in these reports: management of information and maternity services governance.

Methods
Ten publically-available national health-service-commissioned inquiry reports on pregnancy loss services from inquiries into the Irish maternity services (published between 2005 and 2018) were analysed. Qualitative data was collected by 2 clinicians, separately, using a specifically designed review tool. Thematic analysis of the findings and recommendations was carried out.

Results
Communication with families should be clear, open and timely; especially relating to pregnancy loss care. For effective continuity of care, it was advised that each patient should have a clear plan of care, and that clinical results be followed-up promptly. Three reports encouraged the introduction of a national early warning chart to identify the deteriorating maternity patient early. Collecting data (e.g. through audit) for national benchmarking and monitoring maternity outcomes was recommended in 90% of reports. Further development of national guidelines for maternity care was advocated. All reports made recommendations in relation to maternity service clinical governance, including the need for effective leadership and management, with adequate human resources.

Conclusion
Standardised or structured communication procedures are useful to transfer patient information between staff effectively. Communicating sensitively with families, especially after a bereavement can significantly reduce their distress. Relevant recommendations made within inquiry reports, can have a profound impact on maternity services if implemented appropriately.

Ethics statement:
No ethics approval required.

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