Investigation of Incident 50278 from time of patient’s self referral to hospital on the 21st of October 2012 to the patient’s death on the 28th of October, 2012

Hdl Handle:
http://hdl.handle.net/10147/293964
Title:
Investigation of Incident 50278 from time of patient’s self referral to hospital on the 21st of October 2012 to the patient’s death on the 28th of October, 2012
Authors:
Arulkumaran, Sabaratnam
Affiliation:
St. George’s University of London
Publisher:
Health Service Executive
Issue Date:
11-Jun-2013
URI:
http://hdl.handle.net/10147/293964
Additional Links:
http://www.hse.ie/eng/services/news/savitareport.html
Item Type:
Report
Language:
en
Description:
This investigation was commissioned by the Clinical Director at the Hospital where this tragic maternal death occurred on the 28th of October 2012. The terms of reference for this investigation are within appendix B of this report. The investigation team considered and accepted the terms of reference for this investigation. The terms of reference led the investigation team to form the view that this investigation was to establish the circumstances as to what happened, and whether any aspects of the care of this patient contributed to the untimely and unexpected death of this 31 year old mother following a miscarriage at 17 weeks of gestation. In particular the investigation team sought to focus on a chronology of events leading to this patient’s admission to the Intensive Care Unit from the Gynaecology Ward on the 24th of October, 2012. Where aspects of care were considered to have contributed, a further aim was to identify the underlying causes of these so that such causes can be addressed to improve the care given to mothers experiencing miscarriage in maternity hospitals.
Keywords:
PATIENT SAFETY; CLINICAL GOVERNANCE; MATERNITY SERVICE; MORTALITY

Full metadata record

DC FieldValue Language
dc.contributor.authorArulkumaran, Sabaratnamen_GB
dc.date.accessioned2013-06-14T09:37:04Z-
dc.date.available2013-06-14T09:37:04Z-
dc.date.issued2013-06-11-
dc.identifier.urihttp://hdl.handle.net/10147/293964-
dc.descriptionThis investigation was commissioned by the Clinical Director at the Hospital where this tragic maternal death occurred on the 28th of October 2012. The terms of reference for this investigation are within appendix B of this report. The investigation team considered and accepted the terms of reference for this investigation. The terms of reference led the investigation team to form the view that this investigation was to establish the circumstances as to what happened, and whether any aspects of the care of this patient contributed to the untimely and unexpected death of this 31 year old mother following a miscarriage at 17 weeks of gestation. In particular the investigation team sought to focus on a chronology of events leading to this patient’s admission to the Intensive Care Unit from the Gynaecology Ward on the 24th of October, 2012. Where aspects of care were considered to have contributed, a further aim was to identify the underlying causes of these so that such causes can be addressed to improve the care given to mothers experiencing miscarriage in maternity hospitals.en_GB
dc.language.isoenen
dc.publisherHealth Service Executiveen_GB
dc.relation.urlhttp://www.hse.ie/eng/services/news/savitareport.htmlen_GB
dc.subjectPATIENT SAFETYen_GB
dc.subjectCLINICAL GOVERNANCEen_GB
dc.subjectMATERNITY SERVICEen_GB
dc.subjectMORTALITYen_GB
dc.titleInvestigation of Incident 50278 from time of patient’s self referral to hospital on the 21st of October 2012 to the patient’s death on the 28th of October, 2012en_GB
dc.typeReporten
dc.contributor.departmentSt. George’s University of Londonen_GB
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