September 2016

London maternal deaths A 2015 review

London maternal deaths | A 2015 review

Dedication

This review, report and recommendations are dedicated to the 26 families who have suffered the loss of a partner, wife, mother, sister, daughter or friend.

All of us working within or closely with the NHS in London have a responsibility to these women and the families and friends they left behind, to ensure that the findings from maternal death reviews are learnt from and that there is a cohesive London-wide effort made to share that learning across London and beyond.

London maternal deaths | A 2015 review

Acknowledgements and contributors

The London Maternity Clinical Network wishes to thank those in the maternity units who shared their incident findings and implemented the London-wide process for the investigation of maternal deaths and provided ongoing feedback regarding its use. Their efforts have made this report and the development and embedding of a new London-wide process possible. Special thanks goes to the members of the Maternal Morbidity and Mortality working group for their time, energy and work to undertake the development of the London-wide process, the comprehensive review of all maternal deaths across London and this report.

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ContentsIntroduction 6Key themes from the review 6Setting the scene Background 7Definitions of maternal death 7Context and demographics 8London maternal death review process 8Sites providing London maternity services 8Trends in maternal death figures in London 9Regional view 9Review process 9Primary causative conditions 9Methodology 10Themes identifiedRisk factors overview 11Communication and co-ordination of care across settings 11Declining treatment and appointment non attendance 11Morbidity and medical risk factors 12Women presenting with complexity of conditions 12Policies, guidelines and standards of care 13Identification of deterioration and escalation 13Social risk factors (including drug and alcohol misuse) and mental health 14Delays in care along the pathway and out of hours support 15Areas of good practice identified 15Nine recommendations 16References 17Abbreviations 18Appendix 1: London maternal death review guidance 19

Contents

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This is the first annual report published by the London Maternal Morbidity and Mortality working group. It reviews all of the maternal deaths occurring within London (for which reports were available) in the calendar year 2015. A London-wide process, introduced in July 2015, is in place for all maternity services in the capital. The intention of this London-wide process is to ensure objective investigation, consistency and learning from these tragic events, with the overarching aim of reducing, where possible, severe harm to women and ultimately reducing London’s maternal death rate.

To achieve this, the London Maternity Clinical Network established a register of experts drawn from across all London trusts and CCGs to facilitate objective investigation into maternal death. More than eighty clinicians are on the volunteer register to provide timely and external objective support to trusts following the death of a woman, and this number continues to increase. It is worthy to note that deaths reviewed here prior to the adoption of the standardised template (July 2015) used inconsistent templates with varying levels of detail and information.

This report identifies lessons that can be learned across maternity services on a system-wide level and highlights where care may not be in line with best practice. Themes which have emerged from our review include social isolation and the pregnancy journey for women with very complex co-morbidities already in place.

The London-wide work will continually compare itself to the national work conducted by Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE). This annual report (and all annual reports going forward) will be undertaken on a calendar year basis, providing the most meaningful comparisons with MBRRACE reports.

Foreword

London Maternal Morbidity and Mortality working group

Since its establishment, the London Maternal Morbidity and Mortality group has:

» Introduced a new reporting framework for all maternal deaths which has been adopted by all trusts providing maternity services;

» Undertaken in-depth analyses of 26 maternal deaths; and

» Supported 13 maternal death serious incident panels with relevant and appropriate external expertise.

It is anticipated that next year’s focus will be extensive work on the very real issue of severe maternal morbidity.

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Introduction

Reduction in maternal mortality and severe morbidity has been a key focus area of the Maternity Clinical Network, beginning with the introduction of a new, collaborative London-wide system for reviewing maternal death serious incidents (SIs) across the capital in July 2015. The Maternal Morbidity and Mortality working group aims to improve sharing and learning across all healthcare providers in the capital from severe morbidity and maternal death. With this consistent system in place to investigate maternal death for the capital, the network can now focus on severe maternal morbidity for 2016/17.

This report brings together the learning from all the reports that have been submitted to the clinical network. In future, we intend to include examples of changes needed as a result of the incident investigations, and to share these changes across London maternity services as soon as they are identified in an investigation process.

This report provides insight into maternal deaths for the capital, most especially a pattern of women who have presented with severe pre-existing medical complexities in a significant number of the cases. This includes three cases where women who had been transferred into London for high level interventionist services and were already seriously compromised on admission to the London units.

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Key themes

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The complexity of maternity cases in London has increased year on year. Of all the London maternal deaths reviewed, the number of women dying due to indirect causes has increased. This is reflective of what is occurring elsewhere in the UK.

Three of the maternal deaths that occurred were of women with significant co-morbidities who were transferred into London for specialist services. MBRRACE’s Saving lives, improving mothers’ care1 report highlighted that women were likely to die after they had given birth, with a major factor attributed to the neglect of services post-birth:

Although it is clear that mental health problems can affect women from every type of background, a major theme that runs throughout the report is vulnerability.

Many of the women who died were from vulnerable populations, with multiple complex social, medical and mental health factors who needed care from many health and other professionals. Making sure that every woman gets the co-ordinated care she needs at all times to keep her healthy during and after pregnancy, whether that care comes from maternity services, her GP, her mental health team or other hospital and community specialists, is a key action identified.

Background

Prior to July 2015 there was no agreed single London-wide process for the investigation of severe maternal deaths. There was considerable variation of external input included into investigation panels following maternal deaths. In addition, there was no consistent resource in the capital for units to easily and quickly identify suitable colleagues to assist in such an investigation.

The London Maternal Morbidity and Mortality group was set up in early 2015, made up of multidisciplinary members from across London. As it was established, expressions of interest were invited from colleagues across London wishing to assist units in the investigation of a maternal death.

The Maternal Morbidity and Mortality group developed a standard template for the investigation of maternal deaths, which was in use by all London units by early 2016. This standardised template provides rapid sharing and dissemination of London-wide data and lessons to be learnt. Maternity units can send copies of final reports following maternal deaths to the Clinical Network, which in turn can offer support to these services in the early days following a death. Although an optional process, most units voluntarily notify the Clinical Network very soon after a maternal death to access this support.

Definitions of maternal death

The below definitions come from the London Local Supervising Authority (LLSA)2. » Direct deaths: Resulting from obstetric

complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.

» Indirect deaths: Resulting from previous existing disease, or disease that developed during pregnancy and which was not the result of direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.

» Coincidental deaths: From unrelated causes which happen to occur in pregnancy or the puerperium.

» Late deaths: Occurring between 42 days and one year after the end of pregnancy that are the result of direct or indirect maternal causes.

Maternal deaths in London – setting the scene

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Context and demographics

The population of London is now over 8.6 million, and is expected to continue to grow to more than 10 million over the next 20 years4. The London Local Supervisory Authority Midwifery Report for 2015 notes that there are 600,000 London children living in poverty, and Newham has the highest proportion of births in the UK born to non UK-born women. Significant health inequalities are prevalent across the boroughs; for example a significant difference in life expectancy between residents of boroughs2.

London has the lowest birth rate for teenagers and the highest birth rate for women over the age of 45 years. London also has a mobile population, with a relatively high fluctuation compared to the rest of the country2.

London is a vastly diverse city with more than 90 different minority ethnic groups, speaking more than 300 languages. London is home to some of the wealthiest and some of the most deprived people in Britain2.

The 2011 census recorded that 36.7 per cent of London’s population are born overseas, making London the city with the second largest immigrant population in the world behind New York City. According to data from the Office of National Statistics (ONS), more than a quarter (27 per cent) of live births in 2014 in England and Wales were to mothers born outside the UK2.

There are great challenges in the area of mental health in the capital. A greater percentage of Londoners report feelings of low life satisfaction and anxiety as compared to other regions in the country. Admissions to hospital for mental illness are higher than elsewhere in England, as are diagnoses for depressive disorders. Three perinatal mental health networks have been established in London to address the needs of women affected by mental health concerns during and after pregnancy and birth.

London maternal death review process

The intention of this London-wide process is to ensure objective investigation, consistency and London-wide learning from these tragic events, with the overarching aim of reducing, where possible, severe harm to women and ultimately reducing London’s maternal death rate, one of the key objectives of the London Maternity Clinical Network.

To achieve this, the London Maternity Clinical Network established a register of experts drawn from across all London Trusts and CCGs to facilitate objective investigation into maternal death. We ask all London trusts to endorse this initiative to ensure that following a maternal death all services are able to obtain the support, expertise and objectivity this process brings.

A guidance document has been produced to assist trusts with this process (see the London Maternity Clinical Network website) and the guideline3 which is attached as Appendix 1.

Sites providing London maternity services

There are 19 healthcare organisations providing maternity services in 29 units in London. This includes three free standing midwifery led units and one private provider. Changes in service delivery in 2015/16 include: the Royal Free Hospital NHS Foundation Trust merger with Barnet and Chase Farm Hospitals NHS Trust; Ealing Hospital NHS Trust merger with London North West Healthcare NHS Trust and Chelsea and Westminster Hospital NHS Trust merger with West Middlesex University Hospital NHS Trust.

Maternity care in London

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Regional view

The image below provides a breakdown of cases by geographical area for the 26 women who died in London in 2015.

Primary causative conditions

The table below lists the conditions that led to maternal demise. However, as noted previously, many women had other co-existent conditions or pathology and therefore an overlap of conditions is seen in the table below.

* Infectious conditions included two cases of underlying infectious disease.

Trends in maternal death figures in London

The below table shows the annual figures by definition for financial years (Apr-Mar) from 2010 through 20162..

Maternity care in London

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16Direct 6 4 1 5 2 7Indirect 23 19 18 14 21 21Coincidental 2 0 0 0 2 1Total 31 23 19 19 25 29

North Central and East London

North West London

South London

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7

8

26 maternal deaths in London

Condition CasesSepsis / infectious conditions* 5Embolism 4Cerebral event (haemorrhage/infarction) 4Suicide 3Cause not determined / confirmed 2Metastatic disease 2Postpartum haemorrhage 1Homicide 1Ruptured aneurysm 1Acute ketoacidosis 1Cardiomyopathy 1Sudden adult death 1

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Review process

The thematic review process was conducted by the members of the Maternal Morbidity and Mortality group who completed an overarching review of all maternal death reports submitted to the London Maternity Clinical Network. Common themes were extracted following multidisciplinary discussion.

It should be noted that the Maternal Morbidity and Mortality group took evidence of notable practice and areas of learning directly from the root cause analysis carried out by the trust investigation teams and the reports which had been submitted centrally. Using these reports as the sole source of information, the Maternal Morbidity and Mortality group has made no assessment of care from the reports (as may be the remit of MBRRACE, for example). Original case notes were not reviewed as part of the preparation for this report.

As indicated in the thematic analysis and recommendations, the causes of death were usually multifactorial. Some of the recommendations link with the best practice toolkits that the London Maternity Clinical Network has produced (for example, continuity of care) to address elements of shared learning. There are also areas where learning from existing MBRRACE reports could have helped if recommendations had been implemented locally.

Trusts have been surveyed on an ongoing basis to elicit their views on the review process to date. Results from this feedback will be shared with stakeholders in autumn 2016.

Methodology

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Risk factors overview

The image below provides insight into the stratification of risk factors.

Communication and co-ordination of care across settings

It has been recognised that good communication and information sharing (both within and between organisations) are essential to providing excellent care for women. This is of even greater importance when women have complex care needs and multiple care givers are involved. There were six cases of substandard communication between the multidisciplinary clinical teams, both within the same provider organisation and where women were referred across providers. Significant medical and social concerns were not appropriately communicated between primary and secondary services, and in two cases, interpreting services were not accessed when English was not the woman’s first language.

Communication tools, such as SBAR (Situation / Background / Assessment / Recommendation), are increasingly used in maternity services, and this should be encouraged as standard practice.

There is a clear need for an identified lead clinician to co-ordinate management with a multidisciplinary approach, particularly for women who have complex medical and/or social conditions.

Some women had multiple transfers of care across the care pathway, such as home to London Ambulance Service (LAS), A&E, triage and delivery suite, intensive therapy unit (ITU), and specialist services at other hospitals. In these circumstances, effective and robust communication is vital to ensure that senior multidisciplinary team discussions are held across organisations to agree the best place for ongoing care management, and to ensure that transfers are undertaken safely and to a high standard.

There were concerns about appropriate handover of care in a number of the reports. Handovers of care were not always comprehensive, despite clear and well established processes being in place and it was not possible to identify whether consultant to consultant handovers had occurred when transferring between NHS trusts. Lack of effective co-ordination of care between clinical specialities was particularly significant.

It is extremely important to avoid care management situations where specialties work independently, with no single team or lead clinician taking a holistic view of the woman. The Kirkup report into Morecambe Bay5 identified that poor information sharing and communication errors featured in cases that resulted in death or severe harm.

Declining treatment and appointment non attendance

The review found eight women who did not attend appointments and / or declined recommended treatment. The majority of these women were vulnerable due to social or mental health problems.

Themes identified

Most of the women high risk at outset

Significant underlying morbidity / coexisting medical disease

Complex social circumstances (including mental health, addiction, housing, poverty,

social isolation)

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Morbidity and medical risk factors

The review found that many of the women who died had significant existing risk at the outset of pregnancy. This related either to existing medical conditions or disease, obstetric related risk, or social or mental health related risk.

Eighteen women were identified with significant co-existing medical disease. Although not all of these conditions were causative of the maternal death, pre-existing medical conditions render management of pregnancy more complex, and may lead to maternal inability to cope with pregnancy complications. Despite most women being classed as high risk at booking, there was not always senior involvement in management or care planning during and after pregnancy. Nine women were classed as morbidly obese at pregnancy booking (with a body mass index, or BMI, above 30, and in three cases, above 40). This is a risk factor for adverse maternal outcome. Conversely, three women were significantly underweight (with a BMI under 18.5), with limited attention paid to this aspect of management. Although low booking weight is not necessarily a risk factor for adverse maternal outcome, there is evidence for increased risk of preterm labour and poor fetal outcomes6.

Underlying medical conditions that contributed to the maternal deaths reviewed include: diabetes and hypertension, cardiomyopathy, scleroderma, sickle cell disease and a newly diagnosed systemic lupus. Two women died of cancer and one from a pulmonary embolism with underlying malignancy. Tuberculosis (acute and chronic) featured in two women.

Of the women with co-existing medical disease, there was a lack of co-ordinated plans of management. In medically complex pregnant women, it is important to ensure a holistic approach to both the pregnancy and underlying medical disease from the outset and throughout the pregnancy. This must be co-ordinated by a lead clinician. Clinical leadership was not visible in many cases.

The review also found several missed opportunities for escalation to a senior level and non compliance against early warning protocols. (This will also be highlighted later in the report.)

Women presenting with complexity of conditions

The number of women who died who had social risk, in addition to a physical and/or psychological co-morbidity, illustrates the importance of developing, implementing and evaluating a co-ordinated and robust care management approach.

In one exceptional case of social risk reviewed, a woman was found dead at home in an advanced stage of decomposition; she clearly had not been missed by anyone for several weeks.

A number of recommendations were made from the investigations into these deaths. In one case, a woman who failed to attend for antenatal appointments was not followed up. In another case there was a delay in GP referral to book a woman for maternity care. At the subsequent (now late) booking appointment, the referral letter did not include information on the woman’s previous drug misuse.

Some women frequently moved addresses across London, leading to involvement of an increased number of primary and secondary healthcare providers, thus creating a greater risk to continuity of care management. Women often presented at different hospitals other than the maternity booking hospital. The investigation reports for these cases included recommendations for improvement in communication between healthcare providers and professionals. In one case of a woman who had a range of providers involved in her care, the post-mortem identified high levels of tramadol. There was a recommendation that there should be monitoring and review of the nature and quantity of drugs prescribed, with discussion of possible drug interactions.

Themes identified

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Policies, guidelines and standards of care

The review found that in five cases, trust policies and/or guidelines were not followed or were not available. In one instance, there was no guideline available for the management of women classed as morbidly obese in the postnatal period6. In at least four cases, policies relating to the use of Modified Early Obstetric Warning Score (MEOWS) were not followed. The policy around following up women who had not been booked was not observed in another case.

Inconsistent and inappropriate use of MEOWS was a theme in the review. The use of MEOWS is intended to provide a simple and consistent tool for the early identification of women whose vital signs and other observations fall outside normal parameters and require escalation to a clinician with the appropriate expertise to manage the presenting symptoms and underlying condition.

Local guidelines should reflect national recommendations for the use of MEOWS in all care settings. However, guideline recommendations can only be effective in saving lives and avoiding serious morbidity when they translate into embedded clinical care. Multidisciplinary training and local audit on the application of MEOWS, and timely escalation using SBAR (or similar tool), are important elements of safe maternity care.

Identification of deterioration and escalation

Identification of deterioration and escalation was a repeating theme in serious incident investigation reports for adverse maternal outcomes and previous maternal death confidential enquiries, and was also significant in this review. Specifically, this relates to an appreciation of the severity of condition, identification of important signs of deterioration, and escalation to senior staff.

There were seven women where there were delays in recognising deteriorating condition, severity of medical condition, and delay in referral either for investigation or to senior staff that may have contributed to demise. This included lack of recognition of rare illness, and failure to use MEOWS as discussed above. This is not a new finding, nor is it specific to London (MBBRACE report1).

In one case, post delivery monitoring of an increasingly unwell mother did not identify deterioration, and care was not escalated. There was reliance on maternal appearance, rather than recognising the significance of and acting on changing clinical vital signs. It should be noted that women may continue to compensate until the point of collapse. The MBRRACE quality standard recommends that all obstetric women should be nursed in recovery by recovery trained staff.

Two cases involved problems with recognition of the risk of sepsis in women with rare and complex pre-existing conditions. This was accompanied by an associated lack of multidisciplinary team recognition of potential problems that could arise. Therefore there was insufficient planning of care during and/or after pregnancy.

Another instance involved admission of a woman by ambulance to her booking hospital – a considerably longer journey – rather than to the nearest maternity unit. There were problems identifying the seriousness of condition across both services, with further deterioration and delay in review following admission. This case highlights the need for triage and prioritisation of women who are admitted with signs of deterioration and the importance of MEOWS to inform professional judgement and decision making. Where deterioration is recognised, it is vital that senior support can be sought easily and quickly.

Themes identified

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Social risk factors (including drug and alcohol misuse) and mental healthSeveral of the 26 women who died had identified social risk factors. This included five women who were identified at booking as high risk due to social factors (already known to social services; previous child on the Child Safeguarding register; domestic violence; temporary housing; homelessness; reluctance to access services as no recourse to funding for care from the woman’s perspective; misuse of drugs and alcohol; social isolation). Of the 26 women, five were reported not to have attended scheduled appointments on more than one occasion. Four women had a background of depression or other mental illness.

MBRRACE reported that 22 per cent of women who died had mental health risk factors1. This annual review of deaths in London found an even higher rate of 27 per cent. Of note, 10 per cent of women will develop a new mental illness during pregnancy or during the first year post delivery7. Despite this knowledge, the UK still does not have national provision for perinatal mental health services (indicated as a risk factor by the Maternal Mental Health Alliance8).

Four women were known to have mental health risk factors that preceded the pregnancy, one woman developed severe postnatal depression, and one woman developed iatrogenic mental illness as a result of essential medical treatment.

System errors again feature, namely lack of, or difficulty in, communications between inter-professional agencies, and sporadic follow up of missed appointments. In one case social services were unable to be contacted out of hours. There is a need for all maternity units to have one local 24-hour number to call for social services in cases of emergency need (particularly relevant in women being seen ‘out of their area’).

One case highlighted the problem of an incorrect address being entered in the woman’s notes.Dependence on postal services to deliver appointment letters seems outdated in a time when most pregnant women have smartphones and most hospitals have the ability to send appointments by text message, thus avoiding the possibility of an incorrect address. This was highlighted in at least two reports, but not addressed as a priority for service change.

The difficulty in managing complex medical and mental health problems is demonstrated with communication lapses between hospitals and GPs and also between professional clinical teams within the maternity units.

The need for a named clinician to take overall responsibility for these women should again be addressed.

A number of women had multiple social, medical, and mental health needs. The investigation reports for these women demonstrated very high levels of care despite the complexity of over-lapping conditions. It is recognised that women with complex social lives present real challenges for professionals. This was also in addition to pre-existing medical conditions and development of pregnancy complications with post-partum consequences in some cases.

Many maternity services already work closely with children’s centres, local authorities, and other partners in order to provide the best possible support to women with complex social risk factors both in pregnancy and in preparation for parenthood. This co-ordination needs to be developed and enhanced as an increasing number of women bring a very complex socioeconomic background with them to their maternity journey.

Themes identified

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Delays in care along the pathway and out of hours support

In seven cases, the investigation reports identified delays in care and lack of out of hours support as contributory factors. There were delays in implementation of care plans, access to appropriate senior professionals, delays in accessing specialist procedures (such as CT scanning), delays in transfer to appropriate clinical areas and delays in recognition of high risk status and access to appropriate management.

Delays occurred in referrals to more senior clinicians, including senior members of obstetric and other clinical teams when serious maternal illness was identified, as well as ensuring that care management plans were acted on promptly. Examples included delays in taking women to theatre, taking urgent blood samples, interpreting blood results, and commencing medication.

Of note were reported difficulties with calling senior clinical staff out of hours, poor communication between clinical teams, and important clinical information omitted from patient handover.

Delays in triage were noted in a number of cases, even though many London maternity services have set up a triage service alongside the labour ward in recent years. Based on the A&E model, triage is used to identify women in established labour or presenting with other issues who require admission. Some triage areas also signpost women who require the obstetric day assessment unit and the midwifery led birth centre. In some cases, triage has been used to alleviate traffic and workload for the labour ward.

In this review, five maternal deaths occurred where flows through triage were implicated. These were either delays in triage (three cases), lack of information for the midwife to appropriately assess the woman (one case), delay in identifying higher risk women (one case) and one case where it may have been more appropriate for the ambulance service to have taken the woman to A&E.

Areas of good practice identified

During the process of reviewing the SI reports, the working group members were able to identify areas of good practice in examples given below:

» Good postnatal care after diagnosis of cancer during pregnancy

» Appropriate referral to smoking cessation midwife » Appropriate referral to and from social care and

safeguarding team » Woman advised to be admitted to psychiatric

mother and baby unit (MBU) as a result of mental health issues

» Postpartum psychosis managed in a psychiatric MBU

» Timely referral to perinatal mental health unit » Seen by psychiatrist prior to discharge and referred

on to the South London and Maudsley NHS Foundation Trust

Themes identified

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Top nine recommendations

The review has identified the key themes detailed below. It is important to state that implementation of these recommendations does not always necessitate investment in resources but changes to current practice and policies.

1. Standardisation of MEOWSThe group recommends that there should be a standard template, policy and MEOWS chart across London with agreed, identified triggers.

2. IdentificationofanamedclinicalleadThe group recommends that those women with complex risk factors/complexity of conditions must have a named clinical lead responsible for co-ordinating effective, multidisciplinary care.

3. Agreed pan London policy for reaching out to womenThe group recommends that there should be a standardised methodology for following women who consistently fail to attend appointments through the maternity pathway.

4. Communication using digital technologyThe group recommends that trusts should improve the use of mobile telephones and digital technology, rather than rely on postal communication.

5. Continuity of care / carer The group recommends that trusts should fully implement the best practice guidance for continuity of care developed by the London Maternity Clinical Network.

6. London Ambulance ServiceThe group recommends full implementation of the LAS Maternity pre-hospital screening and action tool for appropriate transfer of women to hospital.

7. Implementation of sepsis protocolThe group recommends full implementation of the Sepsis Six bundle across all trusts.

8. Pulmonary embolusThe group recommends that trusts should ensure they are following appropriate venous thromboembolism (VTE) guidelines in identifying those women with a risk of pulmonary embolus including provision of clear information to the women and their families.

9. Understandable informationThe group recommends that it is of vital importance that there should be appropriate use of interpreting services for women for whom English is not their first language. Trusts should ensure that family members are not used as interpreters.

5. Continuity of care best practice guidance | www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-coc-toolkit-042015.pdf 7. Sepsis Six bundle | www.survivingsepsis.org/SiteCollectionDocuments/SSC_Bundle.pdf

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1 MBRRACE-UK report 2015Saving lives, improving mother’s care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009-13www.npeu.ox.ac.uk/mbrrace-uk/reports

2 London Local Supervisory Authority Annual report to the Nursing and Midwifery Council (1 April 2015-31 March 2016) www.londonlsa.org.uk/pdf/annual_report/London_LSA_Annual_Report_2015-2016.pdf

3 London Maternity Clinical Network London maternal death review guidance (April 2016) www.londonscn.nhs.uk/wp-content/uploads/2016/09/mat-death-review-guidance-042016.docx

4 Greater London Authority Children in poverty (2015) http://data.london.gov.uk/dataset/children-poverty-borough

5 Dr Bill Kirkup CBE The report of the Morecambe Bay investigation (2015) www.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_ Accessible_v0.1.pdf

6 National Institute for Health and Care Excellence Weight management before, during and after pregnancy [PH27] (2010) www.nice.org.uk/guidance/ph27

7 NHS Improving Quality Improving access to perinatal mental health services in England: A review (2015) www.nhsiq.nhs.uk/media/2696378/nhsiq_perinatal_mental_health_sml__0915final.pdf

8 Maternal Mental Health Alliance http://maternalmentalhealthalliance.org

References

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BMI Body mass indexCCG Clinical commissioning groupCT Computerised tomographyGP General practitionerITU Intensive therapy unit LAS London Ambulance ServiceLLSA London Local Supervising AuthorityMBRRACE Mothers and Babies: Reducing Risk through Audits and Confidential EnquiriesMBU Mother and baby unit MEOWS Modified Early Obstetric Warning ScoreONS Office of National StatisticsSBAR Situation / background / assessment / recommendationSI Serious incidentVTE Venous thromboembolism

Abbreviations