14 - Confidential enquiries into fetal, neonatal and maternal death

Summary

Introduction

Until April 2003 there were two separate bodies collecting information and making enquiries into maternal and perinatal deaths in the UK. The Confidential Enquiries into Maternal Deaths (CEMD) produced triennial reports entitled “Why Mothers Die” from 1952 up to and including the report for 1997/9. The Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) produced annual reports in addition to focused reports (e.g. Project 27/28).

These two bodies are now combined into the Confidential Enquiry into Maternal and Child Health (CEMACH). This is a self-governing body managed by its own board with members nominated by eight Royal Colleges. The remit of CEMACH includes the improvement of maternal and child health as well as mortality reviews. To this end, CEMACH has not only continued the Why Mothers Die report and the Stillbirth Neonatal and Postnatal Mortality report but also undertakes focused enquiries e.g. The Diabetes Study.

The National Institute for Health and Clinical Excellence (NICE) currently takes overall responsibility for the publishing of these reports, however this role will be short lived and is soon to be handed over to the National Patient Safety Agency (NPSA).

All maternal deaths should be reported to CEMACH Regional Manager, who then initiates an enquiry by sending a standard form to all professionals concerned with the care of the woman. The Trust must hold an internal investigation to ascertain what happened, and the Strategic Health Authorities, Primary Care Trust, coroner, and Local Supervising Authority Midwifery Officer (LSAMO) should also be informed.