Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Clinical Skills, Evidence, Governance and Professional Practice Syllabus

How does clinical audit differ from research?

Audit measures practice against an existing accepted standard to improve local care; it does not create new knowledge and usually needs no ethics approval. Research seeks to generate new generalisable knowledge, tests hypotheses, may randomise/use placebo, and requires ethics committee approval.

Describe the PDSA cycle in quality improvement.

PDSA = Plan (objective, predictions, plan the change/data collection), Do (implement on a small scale, record observations), Study (analyse data against predictions), Act (adopt, adapt, or abandon the change). Iterative small-scale cycles drive incremental improvement.

What is a run chart and what is special-cause variation?

A run chart plots a measure over time to detect trends, shifts, or runs. Common-cause variation is the inherent random noise of a stable process; special-cause variation is a signal from an identifiable external factor (e.g. a run of points on one side of the median, or a trend), indicating the process has changed.

In risk management, what is a risk matrix and how is risk scored?

A risk matrix grades risk by combining likelihood and consequence: $$\text{Risk score} = \text{Likelihood} \times \text{Consequence}$$ Each is typically rated 1-5, giving scores 1-25, banded into low/moderate/high/extreme to prioritise action and escalation.

Define a 'never event' and give an obstetric/gynaecological example.

A never event is a serious, largely preventable patient safety incident that should not occur if available preventive measures are implemented. Examples: retained swab or instrument after surgery, wrong-site surgery, or wrong-route administration of medication.

What is a root cause analysis (RCA) and when is it triggered?

RCA is a structured retrospective investigation of a serious incident to identify underlying contributory and root causes (not to apportion blame) and generate actions to prevent recurrence. It is triggered by serious incidents/never events and uses tools such as fishbone (Ishikawa) diagrams and the '5 whys'.

What is the difference between Datix incident reporting and the duty of candour?

Datix (incident reporting) is the internal system for logging adverse events/near-misses to enable learning. Duty of candour is a statutory/professional obligation to be open and honest with patients when something goes wrong: inform them, apologise, explain, and offer remedy/support.

Distinguish between a guideline, a protocol, and a care bundle.

A guideline is evidence-based, systematically developed guidance to assist decisions (allows clinical judgement). A protocol is a precise, prescriptive set of steps to follow with little deviation. A care bundle is a small set of evidence-based interventions that, when performed together reliably, improve outcomes (e.g. sepsis six).

What does the GRADE system assess when developing guidelines?

GRADE rates the certainty (quality) of evidence as high, moderate, low, or very low, and separately the strength of recommendation (strong vs weak/conditional). It downgrades for risk of bias, inconsistency, indirectness, imprecision, and publication bias; upgrades for large effect, dose-response, plausible confounding.

What is MBRRACE-UK and what does it surveil?

MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) is the national collaboration conducting surveillance and confidential enquiries into maternal deaths, stillbirths, and neonatal deaths, producing recommendations to improve care. It continues the work of the former CEMACH/CMACE enquiries.

Define a maternal death and distinguish direct from indirect maternal deaths.

A maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy from any cause related to or aggravated by the pregnancy (not accidental/incidental). Direct deaths result from obstetric complications (e.g. haemorrhage, pre-eclampsia, VTE); indirect deaths result from pre-existing or new disease aggravated by pregnancy (e.g. cardiac disease, epilepsy).

Differentiate early, late, and 'late' maternal deaths by timing.

Death during pregnancy or up to 42 days postpartum = direct/indirect maternal death. Late maternal death = death between 43 days and 1 year after the end of pregnancy from direct or indirect causes. Coincidental (fortuitous) deaths are from unrelated causes occurring in pregnancy/puerperium.

Define the perinatal mortality rate, stillbirth rate, and neonatal mortality rate.

Perinatal mortality = stillbirths + early neonatal deaths (first 7 days) per 1000 total births. Stillbirth rate = stillbirths (≥24 weeks in the UK) per 1000 total births. Neonatal mortality = deaths in the first 28 days per 1000 live births.

In human factors, describe the Swiss cheese model of accident causation.

Reason's Swiss cheese model depicts system defences as slices of cheese with holes (latent and active failures). An accident occurs when holes in successive layers momentarily align, allowing a hazard to pass through all barriers. It emphasises a systems approach over individual blame.

What is the difference between an active failure and a latent condition?

Active failures are unsafe acts by people at the 'sharp end' with immediate effect (slips, lapses, mistakes, violations). Latent conditions are 'blunt-end' systemic weaknesses lying dormant (poor design, staffing, faulty equipment, culture) that predispose to active failures.

List the four pillars (principles) of medical ethics.

Autonomy (respect the patient's right to self-determination), Beneficence (act in the patient's best interest), Non-maleficence (do no harm), and Justice (fairness in distribution of resources and treating patients equitably).

When can confidential patient information be disclosed without consent?

When required by law (e.g. notifiable diseases, court order), or when in the public interest to prevent serious harm/crime (e.g. risk to others, safeguarding), or when sharing for direct care with implied consent. Disclosure should be the minimum necessary and justifiable.

State the components of valid consent.

Valid consent requires that the patient has CAPACITY, is given sufficient INFORMATION (including material risks and reasonable alternatives), and gives consent VOLUNTARILY (free from coercion). Consent can be verbal, written, or implied and must be ongoing.

What did Montgomery v Lanarkshire (2015) establish about consent and risk disclosure?

Montgomery established that the standard for risk disclosure is patient-centred, not doctor-centred (replacing Bolam for consent). Doctors must disclose any 'material risk' — risks a reasonable person in the patient's position would attach significance to, or that this particular patient would — and reasonable alternatives.

List the four-stage test for assessing capacity under the Mental Capacity Act 2005.

A person lacks capacity if, due to impairment of mind/brain, they cannot do one or more of: 1) Understand the relevant information; 2) Retain it (long enough to decide); 3) Use or weigh it in the decision; 4) Communicate the decision. Capacity is decision- and time-specific.

State the five statutory principles of the Mental Capacity Act 2005.

1) Assume capacity unless proven otherwise; 2) Support the person to make their own decision before deeming them unable; 3) An unwise decision does not mean lack of capacity; 4) Acts for someone lacking capacity must be in their best interests; 5) Choose the least restrictive option of their rights and freedoms.

At what gestational age is the legal upper limit for most abortions in Great Britain under the Abortion Act 1967 (as amended)?

24 weeks for the most commonly used ground (Ground C — risk to the woman's physical/mental health). There is no upper limit where there is grave permanent injury/risk to the woman's life (Grounds B, C-life, F), or substantial risk of serious fetal handicap (Ground E). Two doctors must agree in good faith (except emergencies).

What does Gillick competence / the Fraser guidelines address?

Gillick competence assesses whether a child under 16 has sufficient maturity and understanding to consent to their own treatment without parental knowledge. Fraser guidelines specifically apply to contraceptive/sexual health advice: the young person understands the advice, cannot be persuaded to involve parents, is likely to continue intercourse, their health will suffer without treatment, and it is in their best interests.

In safeguarding, what is the difference between a child in need and a child at risk (Section 17 vs Section 47)?

Under the Children Act 1989, Section 17 covers a 'child in need' — requiring support services to achieve a reasonable standard of health/development. Section 47 triggers when there is reasonable cause to suspect a child is suffering or likely to suffer significant harm, mandating a formal safeguarding investigation.

What are the four categories of child abuse?

Physical abuse, emotional abuse, sexual abuse, and neglect. Fabricated or induced illness (FII) is also recognised. Domestic abuse and exposure to it are increasingly recognised safeguarding concerns.

What is the legal threshold of fetal viability in the UK and its relevance to stillbirth registration?

24 weeks' gestation is the legal threshold of viability in the UK. A baby born showing no signs of life at or after 24+0 weeks is registered as a stillbirth; a loss before 24 weeks is a miscarriage. Babies showing any signs of life at any gestation are live births.

Outline the SPIKES protocol for breaking bad news.

S — Setting (private, prepared, support present); P — Perception (find out what the patient already knows); I — Invitation (ask how much they want to know); K — Knowledge (give information clearly, warning shot, avoid jargon); E — Emotions (respond empathically); S — Strategy and Summary (plan and follow-up).

What does the SBAR communication tool stand for and when is it used?

S — Situation (who/what is happening now); B — Background (relevant context/history); A — Assessment (your evaluation of the problem); R — Recommendation (what you need/want done). SBAR is a structured handover and escalation tool that standardises clinical communication and reduces error.

What are the key principles of effective clinical handover?

Handover should be structured (e.g. SBAR), occur in a quiet environment with minimal interruptions, transfer responsibility explicitly, include outstanding tasks and anticipated problems, allow questions/read-back, and be documented. It is a recognised high-risk point for error and information loss.

What is shared decision-making and how does it differ from informed consent alone?

Shared decision-making is a collaborative process where clinician and patient jointly make decisions using the best evidence AND the patient's values/preferences, often aided by decision aids ('no decision about me without me'). It is broader and more bidirectional than informed consent, which is a discrete legal/ethical event of agreeing to a specific intervention.

What are the six data protection principles relevant to electronic health records under UK GDPR?

Personal data must be: 1) processed lawfully, fairly, transparently; 2) collected for specified, explicit purposes (purpose limitation); 3) adequate, relevant, limited (data minimisation); 4) accurate and kept up to date; 5) kept no longer than necessary (storage limitation); 6) processed securely (integrity and confidentiality). The controller is accountable (7th overarching principle).