Psychiatric deaths: Specific recommendations

New to this Enquiry 2003-05:

All professionals involved in caring for pregnant women who have been referred to child protection services should be alert to the fact that many of these women actively avoid maternity care despite being at high risk of medical or mental health problems. This risk is compounded by child protection case conferences and the removal of infants into care. Whilst the needs of the child must remain paramount, extra support and vigilance is needed for the mother and communication between all agencies involved in her care is essential. Further efforts are required to retain women who are substance misusers in treatment programmes after their child has been removed. Social workers should liaise with, and refer pregnant women in their care to, the local maternity services if necessary.

Extra vigilance and support is required for women who have requested a termination but, because of late gestation or other reasons, have to continue with an unwanted pregnancy. All women, but particularly the most vulnerable and excluded who have little money and a lack of transport, should have easy access to local facilities. Careful consideration should also be given to the method employed as medical terminations are particularly distressing for women who are home alone.

As in previous Reports:

All women should be routinely asked in early pregnancy about current and previous mental health problems including their use of prescribed and non-prescribed medicine and legal and illegal substances including tobacco and alcohol. Maternity staff should sensitively, but explicitly, enquire into the nature and severity of these problems. They should check with the woman’s General Practitioner (GP) for further information.

During pregnancy, all women who are at identified risk of serious postnatal mental illness should be assessed by a psychiatric team. The woman should have a management plan which includes a system of close supervision following birth. Midwives should check on the continuing mental health of all their clients at least twice during pregnancy and following delivery.

Midwives should routinely inform the GP that their patient is pregnant and ask for any health or relevant social information. The responsibility of conveying previous psychiatric and medical history should not rest with the woman alone.

GPs should communicate not only with obstetricians, but also with midwives, details of their patient’s previous psychiatric history including that of alcohol and drug misuse.

Psychiatric teams caring for women with serious mental illness, particularly bipolar disorder, should proactively discuss with all female patients of childbearing age the risks associated with childbirth and plans to manage this risk should they become pregnant.

Psychiatric teams should liaise with midwives and obstetricians about the management of pregnant women with mental health problems. Psychiatric teams should accept direct referrals from midwives.

The training programmes of midwives, general practitioners, obstetricians and psychiatrists should include perinatal psychiatric disorders.

Specialist perinatal psychiatric teams should be available to every maternity network or Trust to assist in the management of women who are at risk of becoming ill and to those who are suffering from serious postpartum disorders.

Women who require to be admitted to psychiatric hospital following delivery should be admitted to a specialist psychiatric mother & baby unit.

Substance abuse

Pregnant women with substance misuse problems should not be managed by GPs and midwives alone but by an integrated specialist service nested within the maternity services. This should comprise a specialist midwife and obstetrician, specialist drug treatment professionals who can manage both alcohol and drug problems, a social worker and other relevant agencies to ensure coordinated multidisciplinary and multi-agency care.

Close multidisciplinary and multi-agency care should be continued not only through pregnancy but also in to the postnatal period even if the infant is removed into the care of the local authority.

All drug and alcohol specialist services should enquire about domestic abuse at assessment and within ongoing treatment. Local protocols should be developed for effective collaboration between agencies and services.

All drug treatment agencies should record an agreed minimum consistent data set about the children of clients presenting to them and information should be shared between social services and health treatment agencies.