Peripartum Collapse and Amniotic

Fluid Embolism

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Policy Title:
Executive Summary:

Supersedes:

Peripartum Collapse and Amniotic Fluid Embolism

To aid early identification of a problem so that appropriate
and evidenced based management can be implemented.
This will then improve the outcome for mother and baby in
what can be a rare but potentially fatal event e.g. Cardiac
arrest in 1:30,000 deliveries, amniotic fluid embolus in 17 in
100 000 deliveries.
Previous guideline Version 2.0

Evidence from the RCOG Green Top Guideline Number 52

2011
Trust format & Equality analysis tool
Involvement of Consultant Obstetrician and Anaesthetist
and Haematologist
This policy will impact on: Families and Wellbeing Business Unit
Description of
Amendment(s):

Financial Implications: Non Known

Policy Area:

Families and
Wellbeing Business
Unit

Version Number:
Issued By:
Author:

3.0
Effective Date:
Maternity Service
Review Date:
Michelle Moran RM
Impact
SoM
Assessment Date
Updated by E Alston
RM SoM
APPROVAL RECORD

Consultation Phase:

Obstetric Clinical lead

Mr R
Deverarj.
Date
Head of Midwifery
Mrs L
Moorcroft
Date
Received for information

Document
Reference:

Peripartum
Collapse and
Amniotic Fluid
Embolism
May 2013
May 2016
May 2013

Committees / Group
Labour Ward Forum, MSLC.
Obstetricians Midwives, GP
Representative, Link Tutor
Lead Anaesthetist,
Resuscitation Officer, Blood
Transfusion practitioner,
Consultant Haematologist
Maternity and Womens
Service Clinical Governance
Committee

Date
May 2013

IT Dept & Legal Services

May 2013

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May 2013

Content

1.0 Policy Statement

1.1 Background
1.2 Organisational Responsibilities
1.3 Planning and Implementation
2.0 Measuring Performance and Audit
2.1 Review
2.2 Definition
2.3 Incidence of Amniotic Fluid Embolism (AFE)
2.4 Pathophysiology
3.0 Clinical presentation
3.1 Communication
3.2 Acute Management
4.0 Fetal Assessment consider peri-mortem Caesarean Section
4.1 Long term Management
4.2 Documentation
4.3 Debriefing
4.4 National Register
5.0 Audit /monitoring compliance of this guideline
6.0 References:
7.0 Equality Anlaysis Tool

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1.0 Policy Statement

Maternal collapse is a rare but life-threatening event with a wide-ranging aetiology.
The outcome, primarily for the mother but also for the fetus, depends on prompt and
effective resuscitation. This guideline supports the practitioner in the recognition and
care of a woman with a peripartum collapse and amniotic fluid embolism
1.1 Background
To aid early identification of a problem so that appropriate and evidenced based
management can be implemented. This will then improve the outcome for mother
and baby in what can be a rare but potentially fatal event. The guidance takes into
consideration the requirement from the National Health Service Litigation Authority
Standard 1 Criterion 6 Labour ward Staffing
1.2 Organisational Responsibilities
Chief Executive
Has ultimate responsibility for the implementation and monitoring of the policies in
use in the Trust. This responsibility may be delegated to an appropriate colleague.
Clinical Leads/Head of Midwifery
Where Clinical Leads/Head of Midwifery are asked to ratify this guideline they are
responsible for the review of the guideline and the final ratification prior to the
guideline actually being implemented. This ratification process will take place
following the consultation and approval process.
Trust Committees
As a group are responsible for the consultation and approval process required during
the development of guidelines for the Trust. The committees are responsible for the
review of guidelines submitted to them to ensure that guidelines are appropriate,
workable and follow the principles of best practice.
All Staff
It is incumbent on relevant staff, when asked, to provide comments and feedback on
the content and practicality of guidelines that are being developed and reviewed. It is
the duty of all staff when asked, to provide assistance during the development and
review stages of guideline formulation.
Stakeholders
Are those people with an interest in a guideline who contribute, comment and agree
to the content of the guideline. They include specific committees, groups or forums,
individual colleagues, whole departments, service users and their families.
1.3 Planning and Implementation
This guideline supports the practitioner in the recognition and care of a woman with a
peripartum collapse and amniotic fluid embolism

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Newly ratified guidelines are included on the maternity newsletter. Relevant staff
have the responsibility to ensure awareness of the contents of the guideline and to
inform their Line Manager of any training needs which may affect their ability to follow
this guideline
2.0 Measuring Performance and Audit
The Trust will measure performance of this guideline as indicated under
Audit/Monitoring Compliance below.
2.1 Review
This guideline will be reviewed every three years or sooner following findings from
audit, changes to national guidance, or in response to clinical practice. The
responsibility for the review of guidelines lies with the Practice Development
Midwives who will report to the overarching Maternity and Womens Service Clinical
Governance Committee.
2.2 Definition
Maternal collapse is defined as an acute event involving the cardiorespiratory
systems and/or brain, resulting in a reduced or absent conscious level (and
potentially death), at any stage in pregnancy and up to six weeks after delivery.
2.3 Incidence of Amniotic Fluid Embolism (AFE)

17 direct deaths per 100 000 deliveries a mortality rate of 0.80 per 100 000
deliveries.
The classical scenario of amniotic fluid embolism usually involves an older,
multiparous woman in advanced labour who suddenly collapses, develops DIC
and dies rapidly thereafter

2.4 Pathophysiology

Amniotic fluid can enter maternal circulation through endocervical veins and
frequently does so without detrimental effect.
In others it causes inflammatory response with rapid collapse similar to
anaphylaxis or septic shock.
The volume of fluid entering the maternal circulation does not seem relevant.
Two main pathological effects are:
1 Haemodynamic collapse
2 Coagulopathy

The haemodynamic collapse appears Biphasic with vasospasm and pulmonary

hypertension in the first phase. 15-30mins later the second phase begins with left
ventricular failure, coronary artery vasospasm and myocardial ischemia.
No single obstetric intervention was identified as a risk factor in the last triennial
report but maternal age over 25yrs does increase the risk (only one woman under
25 in the last 2 reports)

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3.0 Clinical presentation

Clinical picture does not depend on finding fetal squames or debris in the
pulmonary circulation.
Usually in labour but can be ante and postnatal.
Sudden dyspnoea with cardiovascular collapse within minutes.
10-20% present with seizures
40% will follow with coagulopathy
10-15% will present with coagulopathy

In many cases, women who suffer an amniotic fluid embolism report some or all of
the following:

premonitory symptoms:
Breathlessness
chest pain
feeling cold
light headedness
restlessness
distress
panic, a feeling of pins and needles in the fingers
nausea and vomiting.

3.1 Communication

Summon emergency help by phoning 2222 and ask for the

1. Obstetric team
2. Neonatal team should be called early if delivery is likely
3. Cardiac Arrest Team if a cardiac arrest is suspected

The consultant obstetrician and consultant obstetric anaesthetist should be

summoned
Ensure the senior midwife on duty attends
The transfusion laboratory should be contacted as soon as possible to request
blood and blood products as appropriate (ext 1808 between 08:00 and 20:00 and
at other times on mobile phone short code 4450).Consultant Haematologist can
be contacted via switchboard for advice
In the community setting, basic life support should be administered and rapid
transfer arranged, unless appropriate personnel and equipment are available.

3.2 Acute Management

The management of AFE is supportive rather than specific, as there is no proven
effective therapy.
Maternal resuscitation should follow the Resuscitation Council (UK) guidelines using
the standard A, B,C approach with some modification for a pregnant woman.
A = airway
B = breathing
C = circulation
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Airway clear and maintained by:

Aggressive treatment of early collapse with early recourse to intubation,

The airway should be protected as soon as possible by intubation with a cuffed
endotracheal tube
Supplemental oxygen should be administered as soon as possible.
Bag and mask ventilation should be undertaken until intubation can be achieved.

Breathing assess by:

Look, listen and feel for normal breathing for no more than 10 seconds
Ignore any occasional gasps patient may make.
If in doubt treat as though the patient is not breathing.
Supplemental oxygen should be administered as soon as possible.
Bag and mask ventilation should be undertaken until intubation can be achieved
Ensure help has been summoned even if you have to leave the patient to phone
2222 yourself.

Circulation

Check for signs of life, if none present:

Start chest compressions, place heel of hand in centre of chest one hand on top
of the other interlocking fingers. Perform 30 chest compressions at a rate of 100120 beats per min to a depth of 5-6 cm followed by 2 ventilations
A left lateral tilt of 150 on a firm surface will relieve aortocaval compression in the
majority of pregnant women and still allow effective chest compressions to be
performed.
The same defibrillation energy levels should be used as in the non-pregnant
patient.
Continue until resuscitation team arrive
Resuscitation efforts should be continued until a decision is taken by the
consultant obstetrician, and consultant anaesthetist in consensus with the cardiac
arrest team.
Two wide-bore cannulae should be inserted as soon as possible.
Take blood for full blood count, X match 2 units blood as a minimum Preload to
heart should be optimised with rapid infusion of fluids
On top of resuscitation and supportive measures, arrhythmias may develop and
will require standard treatment. Inotropic support is likely to be needed and
measurement of cardiac output may help direct therapy and avoid fluid overload,
as this will exacerbate pulmonary oedema and increases the risk of acute
respiratory distress syndrome
Coagulopathy needs early, aggressive treatment, Plasma substitutes and
treatment must start before results are available and until specific fluids are
applied i.e. Fresh Frozen Plasma, O negative blood, platelets, cryoprecipitate
Ongoing care will require invasive central monitoring
Consider the use of anti coagulant therapy
The incidence of uterine atony is increased in AFE and may contribute to a
postpartum haemorrhage. Refer to the East Cheshire NHS Trust Postpartum
Haemorrhage and massive haemorrhage guidelines
Attention to fluid balance and prevention of multi-organ failure e.g. ARDS, renal
failure, sepsis, neurological handicap is required
Support and care of partner and family should not be forgotten

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4.0 Fetal Assessment consider peri-mortem Caesarean Section

If gestation to 26 weeks watch the time - fetal survival better if delivered within 5
minutes of maternal death, therefore decision needed at 4 min
Perimortem caesarean section should not be delayed by moving the woman it
should be performed where resuscitation is taking place.
The operator should use the incision that will facilitate the most rapid access.
Fetal survival < 15% after 15min.
For many of the causes of maternal collapse early delivery improves the maternal
resuscitation. Therefore normal care re haemostasis, antibiotics and avoidance
of other maternal injury must be considered

4.1 Long term Management

Multi-organ failure

Will need multi-disciplinary care on ITU if mother survives.

ARDS, renal, neurological, sepsis all of particular concern.
Take blood ASAP for FBC, U/E, LFT'S, RBS, Ca, Mg. Urates, Coagulation
including D Dimer, X Match minimum 2 units
Other investigations will depend on clinical picture e.g. XRAY, CT, Blood Gases
Refer to the East Cheshire NHS Trust High Dependency Care guideline

4.2 Documentation

Accurate documentation in all cases of maternal collapse, whether or not

resuscitation is successful, is essential. Where possible ensure a scribe is
allocated to document time and events. Scribe records must be filed in the
maternal records
All cases of maternal collapse should generate a clinical incident form and the
care should be reviewed through the clinical governance process.
Complete a SBAR (Situation, background, assessment, recommendation) form
for all maternal transfers

4.3 Debriefing

Debriefing is recommended for the woman, her family and the staff involved in
the event.

4.4 National Register

All cases of suspected or proven amniotic fluid embolism, whether fatal or not, should
be reported through the monthly card notification system to:
The United Kingdom Obstetric Surveillance System (UKOSS)
The National Perinatal Epidemiology Unit
University of Oxford
Old Road Campus
Old Road
Headington
Oxford, OX3 7LF
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5.0 Audit /monitoring compliance of this guideline

This Guideline will be audited in line with the Key Performance Indicators identified in
the NHS Litigation Authority CNST Maternity Standards 2012/13 - Standard 1
Criterion 6
Minimum Requirements

Method of Assessment

CNST Standard

Labour Ward Staffing

A minimum of 1% or 10
sets, whichever is the
greater of all health
records of women who
have delivered in all
care settings

1.6

Requirement for a
consultant obstetrician
attendance in person

Coordination of audit
Any audits undertaken will be the responsibility of the Practice Development
Midwives
Reporting arrangements
The Practice Development Midwives will report the results of audit to the overarching
Maternity and Womens Service Clinical Governance Committee Any action plans will
be tabled at the overarching Maternity and Womens Service Clinical Governance
Committee by the Practice Development Midwives
Acting on recommendations
The audit recommendations and subsequent action plan will be discussed and
agreed by the overarching Maternity and Womens Service Clinical Governance
Committee.
The Maternity and Womens Service Clinical Governance Committee will agree
which individual will be responsible for action(s) within a specified timeframe. This will
be documented on the action plan and within the minutes from the Maternity and
Womens Service Clinical Governance Committee.
Changes in practice and lessons to be shared
Any required system or organisational change to practice will be discussed and
agreed by the overarching Maternity and Womens Service Clinical Governance
Committee. Changes to practice will be identified and actioned within a specified time
frame. A lead member of the team will be identified to take each change forward.
This will be documented on the agreed action plan and monitored at the Maternity
and Womens Service Clinical Governance Committee on a monthly basis until
completion.
Lessons will be shared with the relevant stakeholders

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These guidelines cannot anticipate all possible circumstances and exist only
to provide general guidance on clinical management to clinicians
This guideline has been assessed using the Equality Analysis Screening Tool
6.0 References:
Advance Life Support Sub- Committee (1998) Advanced Life Support Manual( 5e)
Resuscitation Council , London.
Clark S. (1997) Amniotic fluid embolism:current concepts. Contemp Rev Obstet
Gynaecol. 9(4): 297-301
East Cheshire NHS Trust Ante partum Haemorrhage
East Cheshire NHS Trust Postpartum Haemorrhage Guideline
East Cheshire NHS Trust Massive Haemorrhage Guideline
Lewis G (ed) 2007. The Confidential Enquiry into Maternal and Child Health
(CEMACH) Saving Mothers Lives: reviewing maternal deaths to make motherhood
safer 2003-2005. The Seventh Report on Confidential Enquiries into Maternal
Deaths in the United Kingdom. London. CEMACH.
National Health Service Litigation Authority Clinical Negligence Scheme for Trust
(CNST) Maternity Standards 2012/2013
RCOG Green-top Guideline No. 56 2011. Maternal Collapse in Pregnancy and the
Puerperiuma20112011ternal

Collapse in Pregnancy and the

Resuscitation Council (UK). Resuscitation Guidelines 2012

[http://www.resus.org.uk/pages/guide.htm].
Yerby. M. Maternal and neonatal resuscitation. In: "Sundle H (ed) Emergencies
Around Childbirth .Radcliffe Medical Press Ltd, Oxon ISBN-1 85775 568 5
Yerby M. Amniotic Fluid Embolism. In Sundle H. (ed) Emergencies Around
Childbirth. Radcliffe Medical Press Ltd Oxon ISBN-1 85775 568 5

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7.0 Appendix 1.0

Equality Analysis (Impact assessment)

1. What is being assessed?

Peripartum Collapse and Amniotic Fluid Embolism
Details of person responsible for completing the assessment:
Name:E Alston
Position: Registered Midwife
Team/service: Maternity Services

State main purpose or aim of the policy, procedure, proposal, strategy or service:
(usually the first paragraph of what you are writing. Also include details of legislation,
guidance, regulations etc which have shaped or informed the document)
Maternal collapse is a rare but life-threatening event with a wide-ranging aetiology. The outcome, primarily
for the mother but also for the fetus, depends on prompt and effective resuscitation. This guideline
supports the practitioner in the recognition and care of a woman with a peripartum collapse and amniotic
fluid embolism

2. Consideration of Data and Research

To carry out the equality analysis you will need to consider information about the people who
use the service and the staff that provide it.
2.1 Give details of RELEVANT information available that gives you an understanding
of who will be affected by this document
The population of Cheshire as at the 2005 mid year figures (Cohesia Report 2008) is
684,400.
Age:
17.8% (30,500) of the population in Cheshire East is over 65 compared with 15.9%
nationally. This results in a high old age dependency ratio, i.e. low numbers of
working-age people supporting a high non-working dependant older population. The
percentage of older or frail old is also considerably higher, with 2.3% (8,200)
persons 85 and over compared to 2.1% nationally.
Cheshire East has the fastest growing older population in the North West. By 2016,
the population aged 65+ will increase by 29.0% (8,845) and the population aged 85+
by 41.5% (3,403).
This will have an impact on the number of patients being managed by ECT and the
complexity of the health and social care issues that the older person is experiencing.
In addition the staffing profile of ECT will change to include an increasing number of
staff over 65 in the workforce.

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Race:
The 2005 mid year estimate (Cohesia Report 2008) show that the majority of the
population in Cheshire
(94.6%) is White British, with 5.4% non White British. The Cheshire 2007-10 Local
Area Agreement
identified that minority ethnic communities account for around 3% of the population.
Issues for BME communities include lack of knowledge of services, access to
services, access to translation/interpretation, cultural differences, family values.
Many people from BME communities experience poverty, poor housing and
unemployment which make it difficult for them to lead healthier lives. 4180 migrant
workers registered in Cheshire in 2006/07 and comparison to the midyear population estimates for Cheshire in 2005 strongly suggests that Cheshires
migrant worker population is larger than every individual BME group other than the
White-Other White group.
Gypsies and travellers at the last count (July 2006) the highest number was
recorded in the Borough of Congleton (125). 42% of gypsies and travellers report
limiting long term illness compared to 18% of the settled population, with an average
life expectancy 10-12 years less than settled population. 18% of gypsy and traveller
mothers have experienced the death of a child compared to 1% in the settled
population.
Disability:
There are over 10 million disabled people in Britain, of whom 5 million are over state
pension age. Nearly 1 in 5 people of working age (7 million, or 18.6%) in Great
Britain have a disability.
Hearing loss: 1 in 4 has a hearing problem.
Sight problems: There are 2 million people with sight problems in the UK.
Learning disabilities: There is quite a high proportion of people with learning
disabilities in the local area due to there being a number of residential
homes/institutions in the area.
Problems encountered can be lack of staff awareness, communication issues,
information requirements.
Dementia
Approximately six in 100 people aged over 65 develop dementia and this rises to
around 20 in 100 people aged 85 or over. Dementia affects 750,000 people in the
UK.
Carers
Around 6 million people (11 per cent of the population aged 5+) provided unpaid care
in the UK in April 2001. While 45% of carers were aged between 45 and 64, a
number of the very young and very old also provided care. By 2037, it is anticipated
that the number of carers will increase to 9 million.
Gender
On average in Cheshire, 49% of the population are male and 51% are female
Transgender: No local data available, national trends show:
1/12,000 males, transgender from male to female
1/33,000 females, transgender from female to male
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Specific issues around access to services, specific services for men or women, and
single sex facilities. In terms of the transgender population, GIRES (Gender Identity
Research and Education Society ) gives an estimate of 600 per 100,000. If these
figures were applied to the Cheshire East community based on the 2005 mid year
estimates, there may be around 2,100 trans people in the area.

Religion/Belief
In the Cheshire East area:
Christian
- 80%
Buddhists
- 0.16%
Hindu
- 0.15%

Jewish

- 0.12%

Muslim

- 0.36%

Sikh
Other religion
No religion
Not stated

- 0.05%
- 0.15%
- 11.84%
- 6.67%

The Muslim population has the highest levels of ill health amongst faith groups this
includes higher smoking rates amongst men and higher rates of coronary heart
disease and diabetes.
Sexual Orientation
Lesbians, gay men and bi sexual people (LGB) make up to 5-7% of the UK
population (Dept of Trade and Industry, 2003). 13% of Gay men and 31% Lesbian
women are parents (Morgan and Bell, First Out: Report of the findings of Beyond the
Barriers national survey of LGB people)
The experience and health needs of gay men and women will differ. However, both
groups are likely to experience discrimination, higher levels of mental ill health and
barriers to accessing health care
National Health Inequalities data shows that lesbian, gay, bisexual and transgender
(LGBT) people are e 2001 census showed:
significantly more likely to smoke, to have higher levels of alcohol use and to have
used a range of recreational drugs than heterosexual people. They are also at
greater risk of deliberate self-harm. Although most LGBT people do not experience
poor mental health, research suggests that some are at higher risk of mental health
disorder, suicidal behaviour and substance misuse

2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or

concerns raised either from patients or staff (grievance) relating to the policy, procedure,
proposal, strategy or service or its effects on different groups?)
None
2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a
result of this document?
No

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3. Assessment of Impact
Now that you have looked at the purpose,
etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data
and research you have (part 2), this section asks you to assess the impact of the policy,
procedure, proposal, strategy or service on each of the strands listed below.
RACE:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, racial groups differently?
Yes No x
Explain your response:
No this guideline relates to the care of a woman with a peripartum collapse and or amniotic
fluid embolism care will be offered the same irrespective of race. Staff are aware of the trust
interpreter guidelines, how to access an interpreter and know that family members should not
be used to interpret. All staff need to be aware that the trust is now using the Big word as the
main supplier, with Intralinks as local around the Crewe area.
__________________________________________________________________________
GENDER (INCLUDING TRANSGENDER):
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, different gender groups differently?
Yes No x
Explain your response:
No this guideline relates to the care of a woman with a peripartum collapse and or amniotic
fluid embolism
DISABILITY
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, disabled people differently?
Yes No X
Explain your response:
No this guideline relates to the care of a woman with a peripartum collapse and or amniotic
fluid embolism care will be offered the same irrespective of disability. It may be appropriate
to use BSL interpretation, information in another format suitable to meet their individual needs
and to assist in the care of woman on transfer to the maternity theatre

___________________________________________________________________________
AGE:
From the evidence available does the policy, procedure, proposal, strategy or service,
affect, or have the potential to affect, age groups differently? Yes No
Explain your response:
No this guideline relates to the care of a woman with a peripartum collapse and or amniotic
fluid embolism care will be offered the same irrespective of age. However, consideration will
be given to the increased risk factors associated with the incidence of amniotic fluid embolism
LESBIAN, GAY, BISEXUAL:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes
No
Explain your response:
No this guideline relates to the care of a woman with a peripartum collapse and or amniotic
fluid embolism care will be offered the same irrespective of sexual orientation
_________________________________________________________________________
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RELIGION/BELIEF:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, religious belief groups differently? Yes No
Explain your response:
This guideline relates to the care of a woman with a peripartum collapse and or amniotic fluid
embolism care will be offered the same irrespective of religion/beliefs however any
drugs/blood products used associated with the procedure would be checked to ensure they did
not contain products e.g. porcine, which would conflict with the familys religious beliefs
Staff have access to information on a variety of different cultures and beliefs.
There is a privacy, dignity and cultural beliefs booklet. Staff can access training on equality
and diversity.
____________________________________________
CARERS:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, carers differently?
Yes No
Explain your response:
No this guideline relates to the care of a woman with a peripartum collapse and or amniotic
fluid embolism care will be offered the same irrespective of caring responsibilities
_______________________________________________________________________
OTHER: EG Pregnant women, people in civil partnerships, human rights issues.
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect any other groups differently?
Yes No
Explain your response:
No other impacts identified.

_____________________________________________________________________

4. Safeguarding Assessment - CHILDREN

a. Is there a direct or indirect impact upon children? Yes

No
b. If yes please describe the nature and level of the impact (consideration to be given to all children; children
in a specific group or area, or individual children. As well as consideration of impact now or in the future;
competing / conflicting impact between different groups of children and young people:
Positive impact as it is surgery to support newborn feeding up to 16 weeks
c. If no please describe why there is considered to be no impact / significant impact on children

5. Relevant consultation
Having identified key groups, how have you consulted with them to find out their views and
that the made sure that the policy, procedure, proposal, strategy or service will affect them
in the way that you intend? Have you spoken to staff groups, charities, national organisations
etc?
Labour Ward Forum, MSLC. Obstetricians and Midwives, GP and Lay representative, MSLC
Members, Anaesthetists, Blood Transfusion practitioner, Resuscitation lead

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6. Date completed: May 2013 Review Date May 2016

Have you identified any work which you will need to do
in the future to ensure that the document has no adverse impact?
Action
Lead
Date to be Achieved
None

7. Any actions identified:

8. Approval
and Diversity

At this point, you should forward the template to the Trust Equality
Lead lynbailey@nhs.net

Approved by Trust Equality and Diversity Lead:

Date: May 2013

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