Table 3

Number of cases where themes were noted in local (n=28) and external reviews (n=33)

ThemeLocal reviews
External reviews
National guidelines or good practice points:
 Not followed1124
Senior review mentioned
 Consultant involvement noted1428
 Lack of consultant involvement712
Communication themes reported
  with the patient and family219
  between staff members414
  with the patient and family39
  between staff members411
Comments on documentation
 Some areas of good quality813
 Some areas of poor quality1029
Medication errors noted211
Individual supervisory action recommended40
Reported delays in:
 Obtaining a second opinion23
 Providing treatment (excluding drugs)79
 Administering drugs (eg, antibiotics)35
 Requesting blood or clotting products02
 Gaining access to blood or clotting products02
 Transferring patients (eg, to theatre or the labour ward)26
Suggestions for alternative clinical approach made016
  • 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.