Vincent C A, Martin T, Ennis M
Department of Psychology, University College, London.
Br J Obstet Gynaecol. 1991 Apr;98(4):390-5. doi: 10.1111/j.1471-0528.1991.tb13430.x.
Cases from the files of Action for Victims of Medical Accidents which had resulted in stillbirth, perinatal or neonatal death and long term mental or physical handicap were reviewed. In 41 cases there was both a detailed letter from the parents and an independent review by a senior obstetrician. The reviewer's main criticisms were of inadequate fetal heart monitoring, lack of involvement of senior staff and inadequate records. The fetal heart trace was missing in 7 cases and over half of the remaining 34 traces available were misinterpreted or not acted on. In 17 cases junior doctors failed to recognize fetal distress and managed a delivery that they did not have the experience to deal with. In a further 6 cases, senior staff were called but did not come. Records were criticized for being incomplete, illegible or missing. In a few cases unjustified alterations appeared to have been made. Women reported that on some occasions staff ignored their worries, were unsympathetic and gave too little information. Some parents also experienced considerable difficulty in obtaining a clear explanation of the nature and cause of their child's condition.
对医疗事故受害者行动组织档案中的案例进行了审查，这些案例导致了死产、围产期或新生儿死亡以及长期的精神或身体残疾。在41个案例中，既有父母写的详细信件，也有一位资深产科医生进行的独立审查。审查者的主要批评意见包括胎儿心脏监测不足、高级工作人员未参与以及记录不充分。7个案例中胎儿心脏记录缺失，其余34份可用记录中超过一半被误读或未得到处理。17个案例中初级医生未能识别胎儿窘迫，进行了他们没有经验处理的分娩。另外6个案例中，虽呼叫了高级工作人员，但他们并未前来。记录因不完整、难以辨认或缺失而受到批评。在少数案例中，似乎存在不合理的改动。女性报告称，有些情况下工作人员忽视了她们的担忧，缺乏同情心且提供的信息过少。一些家长在获得关于孩子病情的性质和原因的清晰解释方面也遇到了很大困难。
