SU5MR-I/2012
****Important Note:
1. FOR STILLBIRTH, please complete ALL SECTIONS EXCEPT SECTION 3 and 4
2. FOR NEONATAL DEATH, please complete ALL SECTIONS
3. FOR 28 DAYS - <5 YEARS, please complete ALL SECTIONS EXCEPT SECTION 5 and 6A
A. Reporting Centre/District
Hospital death
....
Fresh Stillbirth
or 22 weeks gestation)
Macerated Stillbirth
( 500g or 22 weeks gestation)
( 500g
MyKid No
Mothers IC
(Please fill in the MyKid number.If there is no MyKid no.,
Fathers IC
fill in new or old IC of mother or father or guardian or any
Guardians IC
other identification document number. Please tick ( ) the
ID document for the ID no given.)
a. Postcode:
b. City/ Town:
c. District:
4.Citizen
Citizen
5. Ethnicity:
citizen only
Malay
Chinese
Indian
Other ID document
d. State:
Orang Asli
Bumiputera Sabah, specify:
Bumiputera Sarawak, specify:
6. Gender:
Male
Female
Indeterminate
7. Immunisation status:
(up to age)
Not applicable
Complete
Not complete
Please specify: ..
Unknown
Mothers details
a. Age
b. Education
level
c. Occupation
d. Marital
status
e. Combined
household
income (RM)
unknown
Fathers details
. years
No formal education
College/University
Primary
years
Secondary
Others, specify:
Please specify: ..
Married
<1000
No Income
Unmarried
unknown
Divorced
1001-3000
3001-5000
On social welfare support
No formal education
College/University
Primary
Secondary
Others, specify:
Please specify:
Widow
5001-7000
unknown
Unknown
7000 and above
SULIT
SECTION 3 : PATIENT S DEATH DETAILS (0 - <5 years)
9a. Date of Birth:
(dd/mm/yyyy)
10. Date and time of
Death:
11.Death Certificate
issued by:
12. Cause of death:
(as in death certificate)
a. Date
/
/
(dd/mm/yyyy)
Medical personnel
specify:
.
b. Time:
AM/PM
14.
Hospital
Treatment:
( Tick ()
one)
a. Highest
level of care
received:
PICU
SCN/NICU
b. Highest level of
person managing
HO
MO
Main ICU
PHDW
Others:
specify
A&E
Labour room
Specialist
Consultant
Others: specify
Health clinic
Private clinic
University clinic
Alternative Birthing Centre
Home
Caretakers house
Nursery
En route/ during transport
At the scene (eg accident site)
Duration (day(s) OR
hours(s) if less than a
day):
Lethargy
Unconsciousness
Not able to drink /feed
Others, specify
Duration (day(s) OR
hours(s) if less than a
day):
Please complete number 17 ONLY IF you () one or more boxes in 16 (Except Not Applicable)
( Tick () one)
17. Treatment(s)
received for
current illness?
Yes
Please attach
additional
information if any
Not applicable
No
Please attach
additional information
if any
No of times:
Self-medication
Traditional / complemen
ary treatment
No transport
Unaware child is seriously i
l
Others, specify..
SULIT
18.Co-Morbid
Condition
( Tick () one)
Yes
No
Not applicable
Cerebral Palsy
Chronic Lung Disease
Malnutrition
Congenital Anomaly, specify:
Cardiac Disease, specify: ..
Malignancy, specify: ..
Condition from perinatal period, specify:
Immunodeficiency, specify:
Others, specify: ..
Para
abortion .
Unknown
SULIT
29. Classification of Death
(Modified Wigglesworth)
STILLBIRTH
Is it macerated or fresh?
MACERATED STILLBIRTH
Is there any LCM?
FRESH STILLBIRTH
Is there any LCM?
(a) LCM
present
LCM
(a) LCM
present
absent
LIVEBIRTH
Is there any LCM?
(b) Normally
formed MSB
Note:
LCM = Lethal Congenital Malformation
MSB = Macerated Stillbirth
FSB = Fresh Stillbirth
LCM
absent
(c) Asphyxial
condition
LCM absent
Is gestation < 37 weeks
(a) LCM
present
Gestation 37 weeks
Did the baby have an
asphyxia condition
Asphyxial condition
absent
Did the baby die from
infection?
Note:
SB = Stillbirth
ND = Neonatal Death
Infection absent
Are there any other specific causes of death?
Unknown cause
SULIT
SECTION 6: TO BE FILLED UP BY MEDICAL OFFICER IN CHARGE/SPECIALIST AT PLACE OF DEATH
SECTION 6A : SHORTFALLS IN CASE MANAGEMENT (FOR STILLBIRTH AND NEONATAL DEATH):
1. ANTENATAL CARE
Insufficient antenatal care provided /unbooked. If yes, specify
Delay or lack of consultation in high-risk pregnancy .If yes, specify
Inadequate management of
1.3.1
Previous bad obstetric history
1.3.2
Diabetes mellitus
1.3.3
Hypertension/PE/Eclampsia
1.3.4
Anaemia
1.3.5
Post date
1.3.6
Antepartum haemorrhage
1.3.7
Cephalopelvic disproportion
1.3.8
Multiple pregnancy
1.3.9
Premature rupture of membranes
1.3.10
Growth restricted fetus/IUGR
1.3.11
Cervical incompetence
1.4 Failure to effect in-utero transfer. If yes, specify.
1.5 Inadequate/inappropriate maternal drugs
1.5.1 Provider factor (specify). ( Tick () one)
public
private
1.5.2 Patient factor. If yes, specify..
1.6 Patient factor
1.6.1 Non-compliance to medical advice/treatment. If yes,
specify.
1.7 Inadequate maternal monitoring (eg. blood pressure, urine and weight gain)
1.7.1 Misinterpretation of tests
1.7.2 Delay in action taken ( Tick () one)
provider
patient
1.8 Inadequate fetal monitoring (FKC/CTG/Daptone)
1.8.1 Specify.
Comments by Head of Department / Officer-in-Charge: Please attach additional information if any.
Yes
No
NA
1.1
1.2
1.3
Prepared by:
Name:
Designation:
Date:
2. INTRAPARTUM CARE
2.1
2.2
2.3
2.4
2.5
2.6
Unsuitable
place
(home/hospital)
for
delivery.
If
yes,
specify
Failure to perform Caesarean Section on time
2.2.1 Caesarean Section too early
2.2.2 Caesarean Section too late
2.2.3 Hospital factor. If yes, specify
2.2.4 Patient factor. If yes, specify
Induction of labour
2.3.1 Induction of labour too early. If yes,
specify
2.2.2 Induction of labour too late. If yes, specify
Inadequate intrapartum monitoring. If yes, specify
Delay/lack of consultation/action taken. If yes,
specify
ABC
Inadequate management of ( Tick
public
private
() one)
hospital
facilities
Yes
No
NA
SULIT
2.6.1 Preterm delivery
2.6.2 Prolonged labour
2.6.3 Breech and other malpresentation
2.6.4 Fetal distress
2.6.5 Obstructed labour
2.6.6 Instrumental deliveries
2.6.7 Sepsis in mother
2.6.8 Abruptio
2.6.9 Others, specify .
Comments by Head of Department / Officer-in-Charge: Please attach additional information if any.
Prepared by:
Name:
Designation:
Date:
No
NA
3.1
3.2
Prepared by:
Name:
Designation:
Date:
Signature:
Signature:
Date:
Date:
SULIT
SECTION 6B: REMEDIABLE FACTORS (FOR ALL DEATHS) To be filled up by District/Hospital Committee
4. REMEDIABLE CLINICAL FACTORS:
Present
Absent
(Tick which applicable)
Note: HC : Health Centre H PS : Hospital with Paediatric Specialist HN PS : Hospital with no Paediatric Specialist
H O&G: Hospital with O&G Specialist HN O& G: Hospital with no O&G Specialist PR : Private Clinic/Hospital
ANTEPARTUM
HC
H
O&G
HN
O&G
INTRAPARTUM
PR
HC
H
O&G
HN
O&G
PR
POSTPARTUM-< 28 days /
28 days -< 5 years
HC
H PS
HN
PS
PR
Present
ANTEPARTUM
HC
5.1 Paediatrician
5.2 MO with >6/12
experience in Paediatric
5.3 MO experience in
anaesthesia
5.4 O&G Specialist
5.5 Theatre staff
5.6 Laboratory services
5.7 Blood support
5.8 NICU/SCN
5.9 PICU
5.10 Transport
5.11 Inaccessibility/
Remoteness
5.12 Overall ability to
handle the emergency
identified
None
Unavailable
None
Unavailable
None
Unavailable
None
Unavailable
None
Unavailable
Available
Unavailable
Available
Unavailable
Available
Unavailable
Available
Unavailable
Available
Unavailable
Yes
No
Adequate
Inadequate
Absent
H
O&G
HN
O&G
INTRAPARTUM
PR
HC
H
O&G
HN
O&G
PR
POSTPARTUM-< 28 days /
28 days - < 5 years
HC
H PS
HN
PR
PS
SULIT
6. PATIENT/FAMILY FACTORS
Present
Absent
Adequate (8 visits or
more)
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Unbooked
Signature:
Signature:
b.Sequentially list conditions if any leading to the cause listed in a. Enter the UNDERLYING
CAUSE LAST (disease or injury that initiated the events resulting in death)
Yes
No
Not sure
Yes
No
Not Applicable
No
Yes
No
Specify Details:
Undetermined
Verified by:
Designation
Designation
Date
Date
7.8 Consolidation Report : (0- < 5 years) (by District Medical Officer of Health) please use additional sheet
Please include
i. Particular of patient and family
ii. History of current illness
iii. Co-morbid condition
iv. Cause of Death / Classification of Death
v. Preventable Death OR Not Preventable Death
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vi. Substandard Care
vii. Remedial Action {Please specify action taken or on-going action and status of implementation)
Conclusion:
(by District Medical Officer
of Health)
Validated by:
Signature:
Designation:
Date:
b.Sequentially list conditions if any leading to the cause listed in a. Enter the UNDERLYING
CAUSE LAST (disease or injury that initiated the events resulting in death)
8.2 Suspected Child Abuse
and Neglect (SCAN)
8.3 Postmortem
8.4 ICD Classification of
Cause of Death:
( Tick () one)
Yes
No
Not sure
Yes
No
Not Applicable
No
Yes
No
Specify Details:
Undetermined
Conclusion:
(by State Director of
Health)
Validated by:
Signature:
Designation:
Date: