Table 2 Example based on an actual maternal death showing application of the Asking Why Root Cause Analysis (RCA) method

Cause of death: post-partum haemorrhage (PPH) with death in the ambulance during transfer from primary hospital to next level district hospital.

Why was there failure to control post-partum bleeding 4 hours after birth? (from last to first circumstance)

1. The bleeding was not controlled – post-partum haemorrhage and resuscitation was inadequate.

2. The seriousness of the patient’s condition was not recognised or acted upon.

3. There was delay in identifying that the laceration to her cervix was severe and continuing to bleed.

4. The delivery of the baby was not controlled leading to tears in posterior cervix.

5. At the ANC clinic, staff failed to refer a high risk grand multiparous woman for management at a higher level hospital where blood transfusion was available in case of need.

Sequence of events: contributory factors: asking why

Interventions required to address the gaps/weaknesses in health system identified in this case

Why was there inadequate resuscitation prior to transfer, including no blood transfusion?

1. Training on clinical skills and principles of resuscitation.

2. Assessment that the training leads to improved practice (clinical audit) in future.

3. Enquiry as to why blood was not transfused: if it was not available at the primary hospital, this was a higher indication for early transfer or referral for management.

Why was there a delay in detecting PPH? A laceration was sutured post delivery but a deep tear in the posterior cervix was initially missed, then the attempted repair was insufficient with blood loss of at least1 litre over 2 hours.

1. Supervision of management of high risk patients: need for high level of suspicion in grand multiparous woman who develops post-partum bleeding.

2. Training in management of lacerations and tears following delivery, especially those with severe bleeding.

3. Guideline for management of lacerations in high risk patients by the highest level of surgical skills available in that health facility.

Why did the delivery result in lacerations?

1. Training and assessment of proficiency in controlled delivery of baby by skilled birth attendants.

Why wasn’t her hypotension more aggressively managed? It dropped from 100/60 to 80/? over two hours or more. She was given 2 doses of oxytocin in 10 IU boluses. There was poor documentation of the patient’s clinical condition and actions taken.

1. Training in assessment of the seriously ill obstetric patient.

2. Need for a protocol on the use of oxytocin in such cases since this may have contributed to her hypotension.

3. Need for evaluation of clinical skills of the medical and nursing staff involved with provision of refresher training.

4. Supervision of record-keeping and documentation, with training on competent documentation of the patient’s vital signs, clinical condition and the actions taken.

Why was the woman’s care provided at a primary hospital when she had multiple risk factors? Despite 6 ANC visits her risks were not anticipated.

1. Need for protocol on referral of grand multiparous woman to a higher level hospital due to risk of PPH.

2. Training and supervision of risk assessment by ANC staff.

Patient characteristics: 36 years old, G5P4, HIV positive on ART. She stopped her oral contraception because she wanted to change to an injectable one which was out of stock.

1. Need for training in communication skills: she should have been advised to continue with oral contraception or barrier methods until her alternative preference available.

2. Primary PMTCT of HIV: prevention of unintended pregnancy (abortion not permissible under Botswana law for contraceptive failure despite risk to mother).