Table 2.
Main areas of suboptimal care (grades II/III cases)
|
Oct 1994
|
Oct-Nov 1995
|
Dec 1995-Sept 1996
|
Aug-Dec 1997
|
Jan-July 1998 (excl Apr)
|
Aug 1998-Jan 1999
|
|
|---|---|---|---|---|---|---|
| Baseline (N=14) | Audit 1 (N=7) | Audit 2 (N=54) | Audit 3 (N=29) | Audit 4 (N=26) | Audit 5 (N=9) | |
| Failure to recognize | 4 | 1 | 15 | 4 | 6 | 2 |
| Failure to act | 7 | 5 | 20 | 20 | 9 | 2 |
| Failure in communication | 1 | 0 | 5 | 0 | 2 | 0 |
| Other | 2 | 1 | 14 | 5 | 9 | 5 |
| Most senior person responsible | ||||||
| Consultant | 1 | 1 | 12 | 8 | 5 | 0 |
| Senior registrar/staff grade | ||||||
| Registrar, acting-up | 5 | 5 | 23 | 15 | 10 | 4 |
| SHO, SHO | ||||||
| Midwifery sister, community midwife | 2 | 1 | 11 | 2 | 3 | 2 |
| Staff midwife, student midwife | 4 | 0 | 6 | 4 | 2 | 2 |
| Other | 2 | 0 | 2 | 0 | 6 | 1 |
| SHO=senior house officer | ||||||