Article Text

Download PDFPDF

Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: a case note review study
  1. Fiona Cross-Sudworth1,
  2. Marian Knight2,
  3. Laura Goodwin1,
  4. Sara Kenyon1
  1. 1Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  2. 2Nuffield Department of Population Health, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
  1. Correspondence to Sara Kenyon; s.kenyon{at}


Objectives Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.

Design Anonymised case notes review.

Participants All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012–2014.

Main outcome measures The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.

Results The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).

Conclusions This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time.

  • quality in health care
  • risk management
  • obstetrics
  • clinical governance

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors The study was designed by SK and MK. Data extraction was undertaken by FCS, LG and SK. FCS wrote the first draft of the paper which was commented on by all authors, who have approved the submitted version. All authors had access to the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This paper presents independent research arising from a Research Professorship award to Professor Marian Knight, NIHR-RP-011-032, supported by the National Institute for Health Research. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. This work was also supported by the Collaborations for Leadership in Applied Health Research and Care in the West Midlands (Grant number IS-CLA-0113-10018).

  • Competing interests None declared.

  • Ethics approval Permission was obtained from the Healthcare Quality Improvement Partnership as data controllers to enable access to the anonymised case notes for this secondary case note review study. Research Ethics Committee approval was not required for this secondary analysis of anonymous data.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available for sharing on request from HQIP at

  • Patient consent for publication Not required.