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Simon Ash Profile picture
@OBsleepmerchant
May 16 • 10 tweets • 10 min read Twitter logo Read on Twitter
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Bill Kirkup presents on the independent investigation into East Kent Maternity Services at #Anaesthesia2023 #OBAnes ImageImage
Battled with how to put “In their own words…” together. 4 slides at a time doesn’t cut it. It was a very emotive experience. So I hope this works (Twitter Blue perk)
#Anaesthesia2023 #OBAnes (prelude to #OAA23ASM)
In their own words: FAMILIES.

Midwives, not nurses. They cut me open (@HofkampMichael @emilysharpe @ruthi_landau). He’s singing, then he died. We don’t talk about cesareans. Physician: I’m the doctor. Midwife: we won’t be doing that.

And that last one… apropos of @SQuashie’s… twitter.com/i/web/status/1…
In their own words: STAFF

Big egos, cliquey behaviour (OB, midwives). Made to look stupid. Dread going to work. A successful day: getting to car without tears. OB: hearsay & uncorroborated (until there are how many witnesses? How many errors?). Consultants refuse to come in.… twitter.com/i/web/status/1…
In their own words: AFTERMATH.

That first slide. I didn’t do my job, but I was handing over remember? That’s a PATIENT being asked if she could have done better. Discipline vs reflect. Cover ups. What caused suffering or extended suffering = lies. Grammar >>> #patientsafety. Why… twitter.com/i/web/status/1…
What happened:

Underlying failures - teaming (@AmyCEdmondson keynote from #SOAPAM2023 elsewhere on timeline); respectful workplaces; compassion and listening missing - replicated and repeated cycle of harm. (@SusannaStanford paraphrased in that quote)

Effects on care: most… twitter.com/i/web/status/1… ImageImageImageImage
MISSED OPPORTUNITIES - EIGHT separate clear opportunities to change course, learn, improve between 2010 & 2018. However, reports met with 3 F’s (disbelief, denial and deflection). Arrogance. Any review met with hostility. All is well, good enough.
#Anaesthesia2023 #OBAnes… twitter.com/i/web/status/1… Image
Action now: a different approach required, after an endless cycle of failures. Can’t assume restricted to East Kent (@DOckendenLtd has demonstrated that, hopefully not worse in Nottingham). No detailed operational recommendations- FOUR areas for action: none easy, all… twitter.com/i/web/status/1… ImageImage
Area 1: Maternity Signalling System. Plenty of data, no outcomes. Analyze poorly. Need 4 things. Accept natural variation, trends and outliers.

Area 2: Standards of Behaviour. Staff under strain ≠ excuse bad behaviour. Role models, not teaching. Can’t change vs won’t change?… twitter.com/i/web/status/1… ImageImageImageImage
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More from @OBsleepmerchant

Simon Ash Profile picture
May 23
@TasPirani presents of Liver disease in pregnancy. A lot to cover! #OBAnes #OAA23ASM ImageImage
Physiological changes in pregnancy. Normal LFT/ laboratory changes. #OBAnes #OAA23ASM ImageImage
Causes of liver derangement in pregnancy: flare of pre-existing liver disease (known or unknown). Incidence of pregnancy in people with chronic liver disease at King’s College Hospital. Historically, cirrhotic patients have been infertile d/t anovulation. Population based data… twitter.com/i/web/status/1… ImageImageImageImage
Read 18 tweets
Simon Ash Profile picture
May 22
@ICULone presents on Severe Maternal Morbidity (SMM) and its consequences at #OAA23ASM. #OBAnes Image
Definition of acute SMM: severe, life threatening event during pregnancy & within 6 weeks of delivery. @NPEU_UKOSS provides UK wide high quality obstetric surveillance. Deaths, while uncommon, investigated in depth.

Study Aims: operationalise definition of SMM; report incidence… twitter.com/i/web/status/1… ImageImageImage
SMM at a population level. Study population derivation. #OBAnes #OAA23ASM ImageImage
Read 11 tweets
Simon Ash Profile picture
May 22
Prof Donald Peebles on Embedding Maternal Medicine Networks at #OAA23ASM. Knowing who to call is half the solution to any problem? (Touched on by @elsmere_g during #OBAnes session at #Anaesthesia2023) Image
Direct maternal mortality rate per 100,000 maternities had been decreasing over the last 2 decades, but should a remarkable upswing since 2018, not all accounted for by #COVID19. @mbrrace outlined a case for change: most parts of UK have MDT, but make up variable most without… twitter.com/i/web/status/1… ImageImage
The Maternal Medicine Network (MMN) mandate: ensure timely access to specialist advice and care at all stages of pregnancy. Development of Maternal Medicine specialist centres as regional hub & spoke model = urgent national priority (@DOckendenLtd report)

MMN Ambition and… twitter.com/i/web/status/1… ImageImage
Read 5 tweets
Simon Ash Profile picture
May 21
Dr Katy Sheehan and @ArcBroom present the pick of the posters at #OAA23ASM. 4 criteria for selection of #OBAnes abstracts. ImageImage
A positive start, with the power of positive communication on patient satisfaction, morale & culture, and #patientsafety #OBAnes #OAA23ASM ImageImageImageImage
Barriers to care. Ethnicity, Language and Socioeconomic deprivation. @mbrrace, @TheLancet, and most recently @Anaes_Journal (@LateralTilt @noolslucas @SQuashie @Marianfknight) set the stage. #OBAnes #OAA23ASM ImageImageImageImage
Read 18 tweets
Simon Ash Profile picture
May 21
@NoelleHealy (another 🇮🇪 representative - @ISOA_Ireland well represented!) presents on #OBAnes as a team sport - how do we perform better? at #OAA23ASM. Quite an inspiring quote, then setting the stage with @Fionafionakel et al #humanfactors guidelines in @Anaes_Journal… twitter.com/i/web/status/1… ImageImageImage
Why is teamwork important in OB/ #OBAnes? @mbrrace suggests some lessons to be learned. Prompt action is arguably reliant on good communication, within & between teams. Involving consultant/ specialist care early has been a theme for over a decade. #OAA23ASM ImageImageImage
@DOckendenLtd’ final report highlighted “conflicting agendas and poor teamwork” contribute to adverse maternal & neonatal outcomes? So how do we create good teams?

The @JulieAndrews approach may have the hills alive, but for #OBAnes we may need to start at the very beginning,… twitter.com/i/web/status/1… ImageImage
Read 10 tweets
Simon Ash Profile picture
May 21
@emirakur presents an update on @NAPs_RCoA NAP7 Perioperative cardiac arrest & #OBAnes at #OAA23ASM. ImageImage
The history of @NAPs_RCoA projects and key findings for #OBAnes over the years (failed intubation NAP4 1:390, recent US data 1:808 - gotten better or different methodology?) #OAA23ASM ImageImage
Cardiac arrest in pregnancy. CAPS study @BJOGTweets (I see @Marianfknight?) looked at incidence, management & outcomes in UK. #OBAnes have a significant slice of the pie. @SOAPHQ serious complication repository project (incl. @RichSmileyMD @bscottsegal) provide US data: cardiac… twitter.com/i/web/status/1… ImageImageImageImage
Read 11 tweets

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