Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guideline Platform
  3. Maternity
  4. Back
  5. Common obstetric problems, intrapartum labour ward
  6. Reporting a perinatal death to the Procurator Fiscal (1010)
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Reporting a perinatal death to the Procurator Fiscal (1010)

Please report any inaccuracies or issues with this guideline using our online form

The Crown Office and Procurator Fiscal Service (COPFS) booklet “Reporting deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners” provides a clear concise guide to assist medical practitioners to decide whether a death requires to be reported to the Procurator Fiscal and, if so, how to go about doing this.

 

When to report a Perinatal Death

The death of any baby who falls into the following categories should be reported to the Procurator Fiscal:

  • a sudden, unexpected and unexplained perinatal death including deaths where results of investigations which may explain the death are outstanding
  • where the body of a newborn is found
  • where the death may be categorised as a Sudden Unexpected Death in Infancy (SUDI)
  • which arises following a concealed pregnancy
  • stillbirths / neonatal deaths following maternal trauma / assault / domestic abuse
  • unexplained neonatal death including deaths due to hypoxic ischaemic encephalopathy where the cause for this is unknown
  • neonatal death with unexplained collapse / poor condition at birth

Many intrauterine deaths will be unexplained at the time of birth.  If the obstetric team are in any doubt about whether to submit a report (even if investigations are in progress), it is advisable to discuss the death with the Procurator Fiscal in advance of submitting the report as it will depend on the individual circumstances in each case.

Factors which make a stillbirth reportable will include, but are not limited to, the following:

  • where concerns have been expressed
  • the circumstances will be likely to be subject to an Adverse Event Review
  • it is an unexpected or unexplained intrapartum stillbirth

Timing of report of death to the Procurator Fiscal

All reportable deaths must be notified to the Procurator Fiscal as soon as possible after occurrence and before any steps are taken to issue a death certificate.

In situations where it is not clear if the perinatal death is reportable, discussion with the Procurator Fiscal should take place as soon after birth as possible.

The need to contact the Procurator Fiscal must be considered before a Post Mortem is discussed with the parents, especially if consent for a PM is not going to be given.

If the obstetric team are unsure what to do in a particular case, Dr Penman (Consultant Paediatric and Perinatal Pathologist) can be contacted for advice via switchboard (out of hours on-call service also provided).

Who should make the report?

The doctor with the most detailed knowledge of the circumstances of the death should report it.  For a perinatal death, the on-call Obstetric Consultant should be involved in determining who is to do this.

The death can only be reported by a medical practitioner – the doctor may need to discuss the death with the midwife in advance of reporting it to ensure he/ she has a detailed knowledge of the death and is in a position to provide all relevant information and answer any questions that may be asked about the circumstances of death.

How to report a death to the Procurator Fiscal

The death should be reported to the Scottish Fatalities Investigation Unit (SFIU) team in whose area the significant event leading to the death occurred.

For perinatal deaths which have occurred in NHS Greater Glasgow and Clyde, contact details for the SFIU West team which is based in the Procurator Fiscal’s office in Glasgow are:

SFIU WEST
Telephone: 0300 020 1798
Email: SFIUWest@copfs.gov.uk

In normal circumstances, death reports should be made to the Procurator Fiscal during office hours.  In situations where the death is suspicious, a death report may be made outside office hours to the on-call service, contactable through the police.  This facility should be used in exceptional circumstances only where the matter cannot wait until the next working day.

Information required by the Procurator Fiscal

The reporting doctor should provide the Procurator Fiscal with all of the information required by completing the ‘Notification of Death’ form (ef5 form), a copy of which is contained in Annex 3 of the COPFS guidance (via above link).

An advance call for advice is not a substitute for submitting a completed ef5 if the outcome of the advice call is that the death is reportable to the Procurator Fiscal.

The blank eF5 form will be emailed to you if you do not have access to a copy and should be returned by email to the SFIU West mailbox as soon as possible.

It may be necessary to have a further discussion with the Procurator Fiscal after the eF5 has been received.

The reporting of the death and all discussions with the Procurator Fiscal should be recorded in the mother’s BadgerNet record.

Editorial Information

Last reviewed: 15/03/2022

Next review date: 15/03/2027

Author(s): Jane Richmond.

Version: 1

Approved By: Obstetrics Clinical Governance Group

Document Id: 1010

References

Crown Office & Procurator Fiscal Service (2015). Reporting deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners (last revised May 2019).