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We can confirm that the continuity of the national confidential enquiry into maternal deaths has remained unbroken since 1952. Of note the methodology changed many years ago with a regional support structure replacing the role of the Director of Public Health. This methodology has been updated further (1) with the appointment in June 2012 of the MBRRACE-UK collaboration to run the national confidential enquiry programme. The most recent report ‘Saving Lives, Improving Mothers’ Care’ (2) which reports on the surveillance and confidential enquiries of maternal deaths 2009-2012 across the UK, was published in December 2014 and is available to download from: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
This report contains the anonymised findings of the maternal mortality confidential enquiries and, as a new development, findings from confidential enquiries into the care of women with severe morbidity in pregnancy. This new development is to allow for the identification of additional lessons to improve the safety and care of women and their babies in the future.
The Morecambe Bay report (3) highlights particular concerns over the care of a woman who died from amniotic fluid embolism (AFE). Of direct relevance to this, the ‘Saving Lives, Improving Mothers’ Care’ (2) report contains a chapter describing key messages for the care of women with AFE, based on the anonymised findings of the reviews of the care of eleven women with AFE who died between 2009 and 2012. The main recommendations include rapid perimortem caesarean section when women collapse antenatally, early triggering of the massive obstetric haemorrhage protocol and early recourse to hysterectomy to control bleeding. The whole report emphasises the importance of good communication between all staff involved in the care of women and early involvement of senior staff in the care of women with severe morbidity.
1. Kurinczuk JJ, Draper ES, Field DJ, Bevan C, Brocklehurst P, Gray R, Kenyon S, Manktelow B, Neilson J, Redshaw M, Scott J, Shakespeare J, Smith L, Knight M; MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK). Experiences with maternal and perinatal death reviews in the UK - the MBRRACE-UK programme. Br J Obstet Gynaecol 2014;121 Suppl 4:41-6. doi: 10.1111/1471-0528.12820.
2. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014. ISBN 978-0-9931267-1-0
3. Kirkup B. The Report of the Morecambe Bay Investigation March 2015. UK: The Stationery Office. 2015. ISBN 9780108561306
Competing interests:
No competing interests
10 March 2015
Jennifer J Kurinczuk
National Perinatatl Epidemiology Unit
Marian Knight
University of Oxford
Nuffield Department of Population Health, University of Oxford Old Road Campus, Headington, Oxford OX3 7LF
This news item does not mention the number of maternal deaths in the hospital concerned. For scores of years there used to be Confidential Enquiries in to ALL Maternal deaths. These were initiated by the senior most consultant obstetrician in the region who would send the forms out to the medical officer of health and after 1974, to the district community physician, later the district medical officer....... Who would collect all relevant information, personally studying every medical, nursing, midwifery record, send it back to the regional assessor who would investigate further, finally sending the complete records, his own findings, to the Chief Medical Officer who would publish anonymised findings.
Did all this happen in the present tale of sorrow? Am I mistaken in my memory.
The Chief Medical Officer, or her Principal Medical Officer for Midwifery could be requested by the BMJ to set the record straight.
Re: Substandard care at “dysfunctional” Morecambe Bay maternity unit led to unnecessary deaths
We can confirm that the continuity of the national confidential enquiry into maternal deaths has remained unbroken since 1952. Of note the methodology changed many years ago with a regional support structure replacing the role of the Director of Public Health. This methodology has been updated further (1) with the appointment in June 2012 of the MBRRACE-UK collaboration to run the national confidential enquiry programme. The most recent report ‘Saving Lives, Improving Mothers’ Care’ (2) which reports on the surveillance and confidential enquiries of maternal deaths 2009-2012 across the UK, was published in December 2014 and is available to download from: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
This report contains the anonymised findings of the maternal mortality confidential enquiries and, as a new development, findings from confidential enquiries into the care of women with severe morbidity in pregnancy. This new development is to allow for the identification of additional lessons to improve the safety and care of women and their babies in the future.
The Morecambe Bay report (3) highlights particular concerns over the care of a woman who died from amniotic fluid embolism (AFE). Of direct relevance to this, the ‘Saving Lives, Improving Mothers’ Care’ (2) report contains a chapter describing key messages for the care of women with AFE, based on the anonymised findings of the reviews of the care of eleven women with AFE who died between 2009 and 2012. The main recommendations include rapid perimortem caesarean section when women collapse antenatally, early triggering of the massive obstetric haemorrhage protocol and early recourse to hysterectomy to control bleeding. The whole report emphasises the importance of good communication between all staff involved in the care of women and early involvement of senior staff in the care of women with severe morbidity.
1. Kurinczuk JJ, Draper ES, Field DJ, Bevan C, Brocklehurst P, Gray R, Kenyon S, Manktelow B, Neilson J, Redshaw M, Scott J, Shakespeare J, Smith L, Knight M; MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK). Experiences with maternal and perinatal death reviews in the UK - the MBRRACE-UK programme. Br J Obstet Gynaecol 2014;121 Suppl 4:41-6. doi: 10.1111/1471-0528.12820.
2. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014. ISBN 978-0-9931267-1-0
3. Kirkup B. The Report of the Morecambe Bay Investigation March 2015. UK: The Stationery Office. 2015. ISBN 9780108561306
Competing interests: No competing interests