Number of cases where themes were noted in local (n=28) and external reviews (n=33)
| Theme | Local reviews N=28 | External reviews N=33 |
|---|---|---|
| National guidelines or good practice points: | ||
| Followed | 13 | 28 |
| Not followed | 11 | 24 |
| Senior review mentioned | ||
| Consultant involvement noted | 14 | 28 |
| Lack of consultant involvement | 7 | 12 |
| Communication themes reported | ||
| Good: | ||
| with the patient and family | 2 | 19 |
| between staff members | 4 | 14 |
| Poor: | ||
| with the patient and family | 3 | 9 |
| between staff members | 4 | 11 |
| Comments on documentation | ||
| Some areas of good quality | 8 | 13 |
| Some areas of poor quality | 10 | 29 |
| Medication errors noted | 2 | 11 |
| Individual supervisory action recommended | 4 | 0 |
| Reported delays in: | ||
| Diagnosis | 5 | 22 |
| Obtaining a second opinion | 2 | 3 |
| Providing treatment (excluding drugs) | 7 | 9 |
| Administering drugs (eg, antibiotics) | 3 | 5 |
| Requesting blood or clotting products | 0 | 2 |
| Gaining access to blood or clotting products | 0 | 2 |
| Transferring patients (eg, to theatre or the labour ward) | 2 | 6 |
| Suggestions for alternative clinical approach made | 0 | 16 |
Note that several themes may have been identified for each woman, and therefore the total number of themes identified exceeds the actual number of cases examined.