Direct | Indirect | Total | % cases | |
---|---|---|---|---|
Organizational and/or management total | (42) | (89) | 47 | 84 |
1. Lack of, or failure to implement, policies, protocols, guidelines | 8 | 16 | 24 | 44 |
2. Poor organizational arrangements of staff | 0 | 19 | 19 | 35 |
3. Inadequate education and training | 10 | 8 | 18 | 33 |
4. Poor team work | 5 | 12 | 17 | 31 |
5. Delayed ordering investigations, access to test results or inaccurate results | 4 | 12 | 16 | 29 |
6. Poor access to senior clinical staff | 7 | 8 | 14 | 25 |
7. Inadequate systems/process for sharing clinical information between services: all HV positive | 1 | 10 | 11 | 20 |
8. Failure or delay in emergency response | 5 | 3 | 8 | 15 |
9. Delay in intervention or procedure eg C-section | 2 | 1 | 3 | 5 |
10. Inadequate numbers of staff | UK | UK | UK | UK |
Personnel total | (62) | (96) | 49 | 88 |
11. Lack of recognition of complexity/seriousness of condition | 14 | 25 | 39 | 71 |
12. Lack of knowledge and skills of staff (includes failure to maintain competence, making wrong diagnoses, lack of differential diagnoses leading to linear decision making) | 12 | 25 | 37 | 67 |
13. Failure to offer or follow recommended best practice | 11 | 18 | 29 | 53 |
14. Failure to seek help/supervision/consultation/delay in physician/ICU/anaesthetic consultation | 9 | 10 | 19 | 35 |
15. Failure of communication between staff (entries in medical notes used to communicate between doctors and nurses) | 5 | 11 | 16 | 29 |
16. Delayed emergency response by staff | 8 | 4 | 12 | 22 |
17. Failure of communication of staff with patient or family | 3 | 3 | 6 | 11 |
Technology, equipment and supplies total | (5) | (11) | 14 | 27 |
18. Supplies (IV fluids, blood for transfusion, drugs etc.) out of stock | 4 | 8 | 12 | 22 |
19. Non-availability, malfunction or failure of essential equipment | 1 | 3 | 4 | 7 |
Environment (1 case, 2%) | 1 | 2 | ||
20. Geography eg long distance transfer | 1 | 1 | 2 | |
Barriers to accessing or engaging with care total | (18) | (21) | 29 | 53 |
21. Did not attend for ANC, only had one ANC visit, or late booking | 8 | 12 | 20 | 37 |
22. Not eligible to access free care (non-citizens) | 7 | 4 | 11 | 20 |
23. Lack of recognition of complexity/seriousness of condition by either woman or her family | 1 | 4 | 5 | 9 |
24. Maternal learning disability | 1 | 1 | 2 | |
25. Cultural barriers (attended traditional healer first) | 1 | 1 | 2 | |
26. Social circumstances | 1 | 1 | 2 |