Will these changes prevent a repetition?

In my previous post, about the preventable perinatal death I had missed a report on the Stuff website titled “Hospital procedures to change after mother dies“.

According to this report

An internal investigation by Auckland’s District Health Board (ADHB) was launched after Ms Bayliss’ death, and several procedural changes have followed including a new process for obtaining emergency blood and checking all pregnant women for risk of postpartum haemorrhage.

Assuming this was reported correctly, can we be confident that those reported changes will prevent problems in the future and if we look retrospectively would they have resulted in a different outcome?

Firstly, a disclaimer - we’re working off newspaper reports 5 months after the event - but that’s all we have to work with. The report stated that there were “several procedure changes” but nominated only two - we don’t know what the others were, but presumably the most important ones were reported.

A new process for obtaining emergency blood

What “emergency blood” means I don’t know. If it means the putting aside of blood in case of emergency so it is easily and quickly available when required then yes that will be beneficial.

Checking all pregnant women for risk of postpartum haemorrhage

On the face of it this sounds good - but isn’t it happening already? Certainly in the case of Renee Bayliss it would make no difference as she had been checked (on December 31st) and the risk had been identified.

This last recommendation sounds like a typical shallow response to failure. The only way to really address repetitive failure is with rigorous root cause analysis. When a proper root cause analysis is conducted everything related is put on the table as a possible cause. In our experience, whatever is first considered to be the real reason for failure is never the reason.

Given the identified risk that “Her placenta was also found to be at risk of causing problems, including bleeding following birth” did the investigation include analysis of the clinical decision to choose induction instead of Caesarean? Maybe, I’m hypothesising, that was the root cause and all the rest were contributing factors - I don’t know, but to prevent the preventable all options need to be covered.

Prevention of repetitive failure requires more than “investigation” it requires application of a rigorous process - otherwise it just a …

One Response to “Will these changes prevent a repetition?”

  1. sandee Says:

    I have nothing but contemp for the ADHB. When they exposed 43 pateints to a gruesome disease called cruetzfeldt Jacob disease. (CJD) It was hospital failure all the way as they did not follow there own guidelines. They have not been found accountable. They do not care that everyone who was exposed via the surgical instruments now has a life long watch n wait vigil.

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