Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: a case note review study

Objectives Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews. Design Anonymised case notes review. Participants All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012–2014. Main outcome measures The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed. Results The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140). Conclusions This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time.


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Researchers in Illinois USA compared statewide and regional reviews of maternal death. They found "The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews." Geller, SE et al Maternal & Child Health Journal. Dec2015, Vol. 19 Issue 12, p2621-2626. You may find this interesting Lines 29-30 Please clarify what is meant by a "local team who may not be independent" -independent from whom? Implications?
Lines 35-38. Expand on your observation of an apparent tension between 'no blame' and 'just' cultures … emotional tensions… professional hierarchies. How did you see this in your data? Or do these observations arise from the authors' professional experiences?
Line 38-39 "solutions identified". By whom? How do these solutions track back to the data presented in the paper?

REVIEWER
Serena Donati National Institute of Health, Italy REVIEW RETURNED 20-Mar-2019

GENERAL COMMENTS
The paper is very interesting for those who manage a maternal mortality surveillance system because it highlights the critical issues related to the review process of maternal death cases. It is clear that the quality of the reviews deserves improvement and that this aspect should be properly monitored and evaluated by an enhanced surveillance system . On the other hand the paper could be too specialized for the general public, the descriptive analyzes perhaps a bit poor and the inferability of the results, as reported by the authors, limited. I advise the authors to shorten and simplify the title of the paper.

Reviewer Comments
Changes made Line numb er Reviewer 1: Thank you for this important work to examine number and quality of local reviews of maternal deaths. The paper is well written, mostly clear and worthy of publication. I have a few comments and requests for clarity regarding some of the methods and the discussion.
Thank you. We welcome the comments to improve the paper.  Added to sentence for clarity: These CEs use multi-disciplinary teams of clinicians from outside the region where the woman's death occurred, to review anonymised case notes (medical records) and assess the care given against national guidelines. Assessment is undertaken by these independent reviewers and a consensus regarding whether care was good or improvements were noted, and if so, whether these may have made a difference to the woman's outcome is made at a multi-disciplinary meeting.

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Page 4 Line 43-47. Please clarify whether the 'authors' are the same as the 'investigators'? What are the background/training of the authors and/or investigators?
Yes authors are the investigators and 'between investigators' has been removed to reduce confusion. Two authors are midwives and researchers and were the primary assessors of the case notes and reviews. The other author involved in the assessments is a researcher. All three collaboratively worked together to utilise the proforma in a standardised manner.

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Also are 'notes' the same as 'medical records'? how do 'case notes' relate to these two?
The first reference to case notes 'medical records' has been inserted in brackets to add clarity to the case notes term. Notes, case notes and medical records have been used interchangeablythese terms have been changed where needed, to all state 'case notes '. 9, 55, 158, 160 Line 34 I see an extra comma. n=68,), Removed 162 Page 7 Lines 27-29 Please clarify the first sentence -…"had a documented review on the care received contained within the medical records…." I don't quite understand what this means.
Revised sentence to say: Of the women who died, 60% (n=140) had a documented local review on the care received (have removed the end of the sentence).

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Page 10 Researchers in Illinois USA compared statewide and regional reviews of maternal death. They found "The statewide MMRC found more potential preventability and determined that preventability was associated with provider and systems factors, not patient factors. Observed discrepancies between regional perinatal center and statewide MMRC reviews were likely due to the complexity of cases selected for review, the multidisciplinary external composition of the review team, and the de-identification of cases. Multidisciplinary statewide expert panels should be implemented in addition to local and regionalized reviews. Added following sentence into the Discussion: A comparison of American local and statewide reviews of 31 maternal deaths found that state reviews found more preventable system rather than patient factors when the cases were anonymised and investigated by an external review team.

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Lines 29-30 Please clarify what is meant by a "local team who may not be independent"independent from whom? Implications?
Removed 'not be independent' and added instead: …have provided care or work alongside those who have, which may reduce objectivity.

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Lines 35-38. Expand on your observation of an apparent tension between 'no blame' and 'just' cultures … emotional tensions… professional hierarchies. How did you see this in your data? Or do these observations arise from the authors' professional experiences?
Tension was not seen in the data but arises from observations from professional experience and some literature e.g. Peerally et al, 2017. Added: A balance needs to be maintained between system and individual accountability; reviews should not be a scapegoat exercise while any professional failure must focus on learning and quality improvement.

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Line 38-39 "solutions identified". By whom? How do these solutions track back to the data presented in the paper?
Suggestions that have already been made have had a reference added. Added for clarity: Suggested solutions to support quality balanced reviews include the need for professionalisation… 248, 249 246 Reviewer: 2 The paper is very interesting for those who manage a maternal mortality surveillance system because it highlights the critical issues related to the review process of maternal death cases. It is clear that the quality of the reviews deserves improvement and that this aspect should be properly monitored and Thank you, we agree with the reviewer comment and have added this to the manuscript.

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evaluated by an enhanced surveillance system.
On the other hand the paper could be too specialized for the general public, the descriptive analyzes perhaps a bit poor and the inferability of the results, as reported by the authors, limited.
We agree the paper is too specialised for the general public. We have therefore specifically aimed the paper at healthcare professionals who understand the concept of case review even if they have not been involved in them, and grouping within a BMJ Open specific topic area will emphasise this. The analysis has been strengthened by the suggested comments from the reviewers and made more generally applicable by reference to additional data from the US, as well as existing maternal mortality surveillance systems. It supports existing evidence that local reviews are often not consistent or robust and do not prevent reoccurrence. While there are always limitations to studies, we consider that this study's limitations do not negate the impact of the findings and the potential transferability of the results. We believe that additional highlighting of the role of enhanced surveillance systems, as the reviewer notes above, strengthens the vitally important message of this article in supporting a rising awareness of the need to improve learning from critical incidents.
-I advise the authors to shorten and simplify the title of the paper.
The title has been shortened to: Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012-2014: a case note review study 1-2