HSIB (Healthcare Safety Investigation Branch) has published the findings of its national investigation: The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period. As the healthcare watchdog prepares for its imminent transformation to the new, more powerful and independently run HSSIB, the latest report explores the challenges and dangers associated with risk assessment for venous thromboembolism (VTE) in pregnancy and after birth.
In the UK, venous thrombosis and VTE are the leading direct cause of maternal deaths which occur during and up to six weeks after the end of pregnancy.
HSIB’s investigation found that multiple competing demands, rushed antenatal consultations and poorly designed risk assessment and records systems are leaving maternity staff unable to provide adequate risk assessment, safety netting, prevention and treatment of this life-threatening condition.
What is VTE?
A venous thrombosis is a blood clot that forms in a vein, blocking or restricting the flow of blood. If part of the blood clot detaches and travels through the bloodstream blocking a blood vessel elsewhere in the body, this is known as venous thromboembolism or VTE. If the blood clot forms in a deep vein, such as in the leg or pelvis, this type of VTE is known as deep vein thrombosis or DVT. DVTs are often associated with long periods of immobility, such as sitting on a long-haul flight or extended hospital bed rest after surgery. When part of the breakaway blood clot blocks or restricts an artery of the lung, this type of VTE is known as pulmonary embolism or PE. PE is a serious and potentially life-threatening condition, with effects ranging from mild symptoms, such as chest pain or difficulty breathing, to sudden cardiac arrest.
Pregnancy increases the risk of serious harm caused by VTE
During pregnancy a pregnant woman/person has a higher risk of developing venous thrombosis than someone of the same age who isn’t pregnant. The risk of VTE during or soon after pregnancy is higher for mothers who:
• have had a previous thrombosis;
• suffer from thrombophilia;
• have a family history of venous thrombosis;
• are over 35 years of age;
• have a BMI over 30 (overweight);
• have pre-eclampsia;
• have just given birth by caesarean;
• have just had a blood transfusion or lost more than a litre (1,000ml) of blood whilst giving birth;
• have had more than two children;
• are immobile for prolonged periods of time;
Pregnancy-related VTE can occur at any stage of pregnancy and postnatally for up to six weeks after birth. This means that midwives are expected to assess the pregnant woman’s/person’s risk factors for VTE regularly throughout and directly after the pregnancy. VTE risk assessments should always take place at the mother’s first (booking) appointment and then again at 28 weeks, if they are admitted to hospital at any time during the pregnancy, and after the birth. A new mother’s VTE risk should also be reassessed if they need to be readmitted to hospital after the birth.
HSIB pointed out that MBRRACE-UK’s investigations have previously highlighted mistakes and inconsistencies in the way pregnant women/people were scored for their risk of VTE. This included healthcare staff not recognising or acting on risk factors for VTE, or failing to understand the significance of signs and symptoms in someone with VTE risk factors, as well as treating the mother with doses of blood-thinning medication which were inadequate for the patient’s weight.
However, HSIB also recognised that there are often risks (such as bleeding) associated with giving blood-thinners to prevent blood clots. They also found that recommended prescribing of such medication in these circumstances has not been tested in clinical trials. MBRRACE-UK also recently reported that, in practice, doctors and midwives find current risk scoring systems difficult to use consistently, and recommended that the NHS develop a simpler and better risk assessment tool. Whilst research is ongoing, national reports continue to recognise VTE safety risks and make recommendations to improve care during pregnancy and postnatally, but action has not been taken to implement the recommendations.
Findings of HSIB’s report on assessment of venous thromboembolism (VTE) risks in pregnancy and after birth.
HSIB found that healthcare staff often find it difficult to carry out a robust assessment of a pregnant woman’s/person’s risk factors for VTE within the complex and busy environment of antenatal clinics, labour wards and postnatal wards. Multiple competing demands, distractions and interruptions, lead to them constantly having to balance risk and safety for their pregnant patients. There is a constant trade-off between thoroughness of assessments and efficiency.
Antenatal booking appointments may not provide enough time for midwives to complete the multiple risk assessments and screening tools which must take place at that important first appointment in pregnancy. In addition, the poor design and presentation of the many forms and risk assessment tools makes it more difficult to carry out risk assessments in a logical and consistent way. HSIB found that MBRRACE-UK’s recommendations for the development of a tool to make the current assessment of VTE risk factors simpler and easy to use have not been acted on.
Regular VTE risk assessment is important, given the life threatening impact of PE or DVT in pregnancy, but the fact that VTE is relatively uncommon means that other competing risks arising from the mother’s health or circumstances in pregnancy can often take priority.
Awareness is an important way to help those affected by VTE in pregnancy recognise and seek help for signs and symptoms of possible VTE. However, HSIB found that maternity staff don’t always discuss with pregnant women/people their risk factors or assessment for VTE, leaving them unaware of the risk or signs and symptoms of VTE.
HSIB found that not all healthcare professionals understand what the national guidance means when it says that VTE risk factors should be assessed when someone presents with an ‘intercurrent problem’ in pregnancy. This means that important opportunities for VTE risk assessment are missed. In addition, maternity and postnatal care staff may not have access to the patient’s full records and important information from previous hospital attendances may not be available to the staff at the time that they are carrying out the risk assessment.
Whilst further research takes place, HSIB is encouraging providers of maternity care to review their organisation’s systems for VTE assessment, and ensure that their maternity staff understand, and provide care in accordance with, national guidance.
Help for families affected by maternal injury or death during pregnancy and birth
HSIB’s national investigation report highlights serious concerns about the extent to which the healthcare system is failing pregnant women/people and their maternity care staff by crowding out potentially life-saving risk assessments and awareness building of this serious condition.
Compared with other conditions and concerns in pregnancy, VTE may be considered as rare, and ranked below other competing priorities by busy maternity staff, but VTE is life-threatening and remains the most common cause of death for mothers during pregnancy, childbirth and postnatally.
Maternal death is devastating and the resulting loss for her partner and children is lifelong and profound. Families who suffer this loss as a result of medical negligence are entitled to substantial compensation to help them meet the significant financial cost of losing a mother and partner, such as loss of income for the family and costs of childcare and domestic help.
Boyes Turner’s claimant (patient) specialist solicitors are experts in helping families who have suffered severe injury and loss from maternity negligence.
If you have been seriously injured or lost a partner or parent as a result of medical negligence, or have been contacted by the NHS’s defence team at NHS Resolution, or by HSIB/HSSIB or MNSI after maternity care, you can talk to one of our solicitors, free and confidentially, by contacting us here.