Local versus external review of cases of severe maternal morbidity

BackgroundMethodical and detailed case review is commonly used as a strategy to improve health professionals’ care of pregnant women, 190 not only through documenting the number and causes of morbidity and mortality, but also through identifying preventable factors. 3, 9 Two approaches have been taken nationally to learning from adverse incidents in maternity care: external anonymised case review (confidential enquiries) 2, 3 and local (facility-based) reviews using tools such as root cause analysis. 168 Neither of these approaches has been applied systematically to investigate cases of near-miss maternal morbidity or compared with each other to assess the impact on local learning from adverse events. The aim of this workstream was to assess what types of severe maternal morbidity undergo local review in the UK and to compare the lessons identified for future care through external review (confidential …