Petussis has re-emerged

Abstract

The Confidential Enquiries into Maternal Deaths (CEMD) is being disbanded and will be incorporated into a new structure called MBRRACE-UK, throughout the UK1. The CEMD, which has been in existence since 1952, was highly valued by clinicians. It had an unbroken 60 year history in existence. It set the bar for higher obstetric standards. It monitored the causes of maternal death and improved safety. It operated through a system of anonymised case records of obstetric deaths. A group of regional and national assessors examined the circumstances around each case. The assessors then made recommendations on the lessons to be learned. The Enquiry had widespread support among obstetricians and was an important voice in advocating better maternal care. It constantly stressed the important of clinical vigilance. It emphasised that old messages need to be frequently repeated and that there is no room for inertia. Its strength was its ability to identify avoidable causes of maternal death in a no-blame culture. This resulted in an almost total buy-in. After preparation of the Report and before its publication all maternal death forms, relevant documents and files related to the period of the report are destroyed and all electronic data is irreversibly destroyed.