Notice: You are viewing an unstyled version of this page. Are you using a very old browser? If so, please consider upgrading

Working with hospitals to maximise the benefits of studies of near-miss maternal morbidity

Principal investigator
Marian Knight (NPEU)
James Walker (University of Leeds), Susan Sellers (St Michael's Hospital, Bristol), Mervi Jokinnen (Royal College of Midwives), Shona Golightly (CMACE), Peter Brocklehurst (NPEU), Jenny Kurinczuk (NPEU), Gwyneth Lewis (NPEU (Former member))
Severe maternal morbidity and mortality
National Institute for Health Research
Start year
End year
NPEU Contact
Marian Knight


Methodological and detailed case review is commonly used as a strategy to improve health professionals' care of women, not only through documenting the number and causes of morbidity and mortality, but also through identifying preventable factors. Two approaches have been taken nationally to learning from adverse incidents in maternity care: expert case review (Confidential Enquiries, as undertaken by CMACE), and peer review, using root cause analysis, as recommended by the National Patient Safety Agency for use at a local level. 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. There is currently no national strategy for local learning from near-miss maternal morbidity and we do not know what approaches are being used locally. This project identified approaches currently in use locally and compared expert case review (confidential enquiry) with local peer review (root cause analysis) to determine differences between the lessons identified for future care.


Journal Articles