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2. welfare
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NATIONAL IMPLEMENTATION GROUP
HSE/HIQA MATERNITY SERVICES
INVESTIGATIONS
Ciarán Browne. National Lead for acute Hospital Services, HSE
ciaran.browne@hse.ie
Anne Bergin. Project Manager, HSE jabergin@coombe.ie
• Quality Assurance Sub-group (develop standardised
instruments for data collection & analysis)
• Sepsis Sub-group (Sepsis Guideline incl. pregnancy, bacterial
infections, dev. latest IMEWS incl. sepsis 6 tool)
• Communications (Communication [Clinical Handover] in
Maternity Services)
• Prescribing for Pregnancy Guidelines (focus on
antibiotics)
• Irish Multidisciplinary Obstetric Emergency
Training Sub-group (IMOET Conference, September 2014)
• Bereavement Care Sub-group
Bereavement Care Sub-group
• Set up February 2014
• Multidisciplinary Sub-group with National
Representation
• Leader Ciarán Browne (National Lead Acute Hospitals)
• Project Manager Anne Bergin
Sub-group Membership
Surname
Bergin
Browne
Byrnes
First Name
Anne
Ciarán
Helen
Professional Role
Project Manager
National Lead Acute Hospital Services
CNM
Place of Employment
Health Service Executive
Health Service Executive
University Hospital Galway
Bolger
June
National Lead for Service User Involvement, Patient Advocacy Unit
Health Service Executive
Coughlan
Barbara
Psychologist and Midwifery Lecturer
University College Dublin
Fenton
Joanne
Perinatal Psychiatrist
Coombe Women and Infants University Hospital
Hunt
Marie
Bereavement Counselling Clinical Midwife Manager
University Maternity Hospital Limerick
Keegan
Orla
Head of Education, Research and Bereavement Services
Irish Hospice Foundation
Kennelly
Máiread
Fetal Medicine Specialist
Coombe Women and Infants University Hospital
McKeown
Moran
Mulligan
Mulvihill
Nuzum
Anne
Mary
Fiona
Aileen
Daniel
Bereavement Liaison Officer
Ultrasound Lecturer
Bereavement Support Midwife
Senior Social Worker
Chaplain
University Hospital Galway
University College Dublin
Our Lady of Lourdes Hospital, Drogheda
Palliative Care Longford / Westmeath
Cork University Maternity Hospital
O’Donoghue
Keelin
Consultant and Senior Lecturer, Obstetrics & Gynaecology
Cork University Maternity Hospital
O’Sullivan
Grace
Rock
Sara
National Development Coordinator, Acute Hospitals. Hospice Friendly
Hospitals Programme
CNM2 Neonatology
Rooney-Ferris
Laura
Information and Library Manager
Irish Hospice Foundation
Shine
Bríd
Clinical Midwife Specialist, Bereavement & Perinatal Mental Health
Coombe Women and Infants University Hospital
White
Martin
Consultant Neonatologist
Coombe Women and Infants University Hospital & Our Lady’s
Children’s Hospital, Crumlin
Woods
Kathryn
Midwife
Midland Regional Hospital Mullingar
Irish Hospice Foundation
National Maternity Hospital, Holles Street
Sub-group activities to date
• Audit (April 2014 and April 2015)
• Bereavement Care Standards following Pregnancy Loss
and Perinatal Death
• National Guideline for Bereavement Care Following
Maternal Death Within a Hospital Setting
• Early Pregnancy Loss Seminar (December 2014)
Maternity Bereavement Service Audit Summary
April 2015 & 2014
Profession
Status (2015)
Previous (2014)
18 Units
19 Units
WTE
CMS F/T or FTE
3
6
CMS Act F/T
1
2
CMS Act P/T
2
N/A
Bereavement Liaison Officer
1
1
MSW Bereavement
1
1
MSW non specialist
6
10
MSW shared with general hospital
5
N/A
MSW shared Community
5
N/A
No MSW service
1
N/A
Chaplaincy Service F/T or FTE (see slide below)
15
5
Chaplaincy Service P/T
2
12
Bereavement Committee
9
N/A
End-of-Life Committee
14
N/A
Bereavement or End-of-Life Committees
17
19
Quiet Room for breaking bad news
10
N/A
Linked from table above
• It is difficult to accurately quantify
Chaplaincy services throughout the maternity
services. Many respondents to the audit survey
describe a 24 hour on-call service as a full time
service. However, a full time, or full time
equivalent, Maternity Chaplaincy service should
describe the presence of a Chaplain during core
working hours who is employed as a member of
staff in the maternity services. Only five
maternity units provide such a service while the
remainder provide a chaplain either part time or
as the need arises.
The 4 Standards
1.
Bereavement Care
2. The Hospital
Bereavement care is central to the mission of the hospital The hospital has systems in place to ensure that
and is offered in accordance with the religious, ethnic,
bereavement care and end-of-life care for babies is
social and cultural values of the parents who have
central to the mission of the hospital and is
experienced a pregnancy or perinatal loss.
organised around the needs of babies and their
families.
3. The Baby and Parents
4. The Staff
Each baby receives high quality end-of-life care that is
All hospital staff have access to education and
appropriate to his/her needs and to the wishes of his/her
training opportunities in the delivery of
parents.
compassionate bereavement and end-of-life care in
accordance with their roles and responsibilities
Standard 1: Bereavement Care
1.1 Bereavement Care at time of Diagnosis
1.2 Treatment Options
1.3 Preparing for Birth
1.4 Care following Hospital Admission for Birth
1.5 Post Natal Care
1.6 Preparation for Discharge from Hospital
1.7 Bereavement Care after Discharge
1.1 Bereavement Care
Statement: All hospital staff are trained to sensitively communicate bad news to
parents in a quiet and private environment and with special consideration of
individual needs and preparedness for the emotional and physical management of
their diagnosis.
Guidelines are in place for identifying the needs of and for
supporting a parent experiencing bereavement in the
maternity services. All relevant staff are aware of and use
these guidelines where appropriate.
Parents who experience bereavement in the maternity
services are cared for compassionately with dignity and
respect.
Staff are aware of current legislation in regard to
termination of pregnancy.
Intrauterine
Fetal
Death,
Stillbirth
and Early
Neonatal
Death
Baby born
with a
Lifelimiting
Condition
Ectopic
Pregnancy
Firsttrimester
Miscarriage
Secondtrimester
Miscarriage
Baby
diagnosed
in utero
with a
Lifelimiting
Condition
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Standard 2: The Hospital
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
A culture of compassionate bereavement care
General governance policies, guidelines and care pathways
Effective communication with parents
The healthcare record
The hospital environment
Monitoring and evaluating bereavement care
Assessing and responding to the baby’s end-of-life care needs
Clinical responsibility and multidisciplinary working
Pain and symptom management
Clinical ethics support
Care after death
Post-mortem examination
Bereavement care
Standard 2:
THE HOSPITAL
The hospital has systems in place to ensure that bereavement care and end-of-life care
for babies is central to the mission of the hospital and is organised around the needs
of babies and their families
.
2.1 A CULTURE OF COMPASSIONATE BEREAVEMENT CARE:
Statement: The Hospital Service Plan includes bereavement care as a core component.
Criterion
There is a clear and transparent hospital ethos of bereavement care in place.
Source
Catlin and Carter (2002); Donovan (2010); SANDS
(2007); ISANDS (2007).
The hospital acknowledges and promotes that all staff play a valuable role in ensuring a culture of compassion.
Recruitment and retention of appropriately trained staff in relevant roles within the specialist bereavement team is
prioritised. This is formally acknowledged by senior hospital management as a core value of the hospital and is
reflected in the decision and actions of the hospital.
Fauri (2000); SANDS (2007); ISANDS (2007).
A designated member of the hospital group management team is allocated responsibility for bereavement care
quality improvement across the hospital group.
RCOG (2008); SANDS Audit tool (2011).
A named member of the hospital management team e.g. Director of Midwifery, Hospital Manager or Lead Clinician is
allocated responsibility and is accountable for developing the structures and processes necessary to implement the
bereavement components of the Hospital Service Plan.
HFH Standards, SANDS Audit tool (2011).
The Hospital Service Plan will allocate appropriate funding for the implementation of the Bereavement Care
Guidelines.
The hospital has a committee with multi-disciplinary representation, including midwifery staff, which is responsible
for overseeing quality improvements in bereavement care and end-of-life care. This committee reports directly to
the senior management team in the hospital/hospital group.
Romesberg (2007); HFH Standards.
Each maternity unit should appoint a dedicated maternity bereavement coordinator who works in conjunction with
the Bereavement Team.
Hospice Friendly Hospitals’ Programme : overview
2007-2013.
Donovan (2010); HFH quality Standards p. 41;
SANDS (2007); SANDS Audit tool (2011); WHO
(2006); Johnston et al. (2000); (Ronsmans), 2001.
Standard 3: The Baby and Parents
3.1
3.2
3.3
3.4
3.5
3.6
3.7
Communicating a diagnosis of a need for end-of-life care
Clear and accurate information
Parental preferences
Pain and symptom management
The dying baby
Discharge home/out of hospital
Communication with the family in the event of a baby’s
sudden/unexpected death or sudden decline in health leading to
death
STANDARD 3: THE BABY AND PARENTS
Each baby receives high quality end-of-life care that is appropriate to his/her needs
and to the wishes of his/her parents.
3.1 Communicating a Diagnosis of a Need for End-of-Life Care
Statement: There is timely, clear and sensitive communication in respect of a diagnosis that their baby’s circumstances may require end-of-life
care.
Criterion
Source
The hospital has a policy and related guidelines to assist in communicating with the parents of a
baby who requires end-of-life care. Staff use and are trained in accordance with their roles to use
these guidelines.
Gold (2007); HFH Standards; SANDS
(2007); ISANDS (2007); Palliative Care
Competence Framework Steering Group
(2014).
The parents are facilitated to discuss the care of their baby with the
Paediatrician/Neonatologist/Palliative Care Consultant and are involved in the decision making
process of care.
Gold et al. (2007); HFH Standards;
SANDS (2007); ISANDS (2007).
Staff are aware of parents’ capacity for understanding and are aware of parents’ specific religious,
cultural and ethnic preferences.
Laing and Freer (2008); Edmonds et al.
(2011); HFH Standards; SANDS (2007);
ISANDS (2007); RCPI (2011); RCPI
(2014).
Confidentiality is always maintained in respect of any matters relating to diagnosis of a possible
need for end-of-life care.
Catlin and Carter (2002); HFH
Standards.
Opportunities are provided on an ongoing basis by the multidisciplinary team for the parents to
clarify issues and concerns about their baby’s well-being.
Willimas, Munson et al (2008); HFH
Standards.
Standard 4: The Staff
4.1
4.2
4.3
4.4
4.5
Cultivating a culture of compassionate bereavement care among staff
Staff induction
Staff education and development needs
Staff education and training programmes
Staff support
4.1 Supporting a Culture of Compassionate Bereavement Care Among Staff
Statement: All hospital staff have access to education and training opportunities in the
delivery of compassionate bereavement and end-of-life care in accordance with their
roles and responsibilities. Staff are supported through training and development to
ensure they are competent and compassionate in carrying out their roles in
bereavement care.
Criterion
Source
Each staff member ensures that s/he is familiar with and guided by the Professional Ethical Code of
Conduct appropriate to his/her role.
Catlin and Carter (2002); HFH Standards.
The hospital ensures that there are education, training and staff programmes in bereavement care
for hospital staff in accordance with the size, complexity and specialties of the hospital.
Engler et al. (2004); Fenwick et al.
(2007); HFH Standards; SANDS (2007).
It is the responsibility of hospital management to outline the responsibilities of each member of
the Bereavement Team and to ensure that all staff are adequately trained and educated at the
point of recruitment and throughout their time as an employee. It is therefore the responsibility of
hospital management to ensure that the education and training needs of staff are assessed and
addressed. Assessment should include local factors, but also ensure that contemporary
developments are incorporated (e.g. competencies; findings from research).
Catlin and Carter (2002); Mancini et al.
(2013); HFH Standards; SANDS (2007).
Hospital staff are competent to deliver high quality Bereavement Care in accordance with best
practice.
Ferguson et al. (2012); Mancini et al.
(2013) ; HFH Standard ; SANDS (2007).
Bereavement Care Standards following
Pregnancy Loss and Perinatal Death
•
•
•
•
Launch of Draft Standards in May 2015
Consultation process
Circulation
Forums (Voluntary Support Groups, Sligo, Cork, Dublin,
Mullingar & Galway)
• Web feedback
• Feedback analysis
• Finalising of the standards
Implementation
Standards
Commitment
Resources
???
Resources
Workstreams (Proposed)
• Develop enabling materials
• Submit resource requirements (multi year plan) and
co-ordinate deployment – Bereavement Specialist Team
• Enhance shared learning of current maternity
bereavement services / resources nationally
• Improvements in referral interfaces
• Improvements in integration points
• Staff Supports whilst supporting bereaved parents
• Parents and voluntary organisations exchange
platform
Enabling materials - Examples
• Self-assessment practical workbooks to assist maternity units
identify their own strengths, weakness and gaps
• Checklists (e.g. as inserts in medical records) to assist day to
day practice (particularly where there are different people
inputting into a case)
• Suggested Key Performance Indicators for Senior Hospital
Management to use
• Audit templates
• Example guidelines on important topics
• Suggested or standardised leaflets for parents / families
• Development of a national website with listed services
available by region
• Standardised role descriptions for Bereavement Specialist
Teams
Other linkages
• Maternity Bereavement Care developments
linked into maternity care improvements
generally
• Maternity Bereavement Care Services linked
into Bereavement Care Services generally and
developing hospital groups
• Implementation linked to developing focus on
palliative care / end of life care / open
disclosure, etc projects
Summary
• Significant work undertaken to date to
produce Draft Standards
• Consultation process will allow positive and
negative feedback on Standards
• Finalisation of Standards
• Implementation set up happening in parallel
• Maternal death guideline also being
developed
National Implementation Group
(Proposed)
• Group and Chair to be established with
specific remit to pursue implementation and
improvements
• Linked to development of new maternity
model and National Maternity Office within
Acute Hospital Division
• Linked with development of Maternity Charter
as well
HSE National Incident Management Team (NIMT) 50278 (2013)
ensure that the psychological impact of inevitable miscarriage is appropriately
considered and that a member of staff is available to offer immediate support and
information at diagnosis. Members of staff should also advise of the availability of
counselling services for women and partners at diagnosis. Care given, including
counselling and support, should be documented. The availability of counselling
services for women, partners and families who have suffered any incident or
bereavement in childbirth should be reviewed, considered and developed as
appropriate at each maternity site.