6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

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Appendix 3: Contributors to the Maternal Death Enquiry for the triennium 2006–08 and CMACE personnelNewcastle officeBelfast officeManchester officeCardiff officeCork officeMrs M RenwickDr A Bell/Ms J GluckMrs J Maddocks/Ms P NorrisMrs D Roberts/Mrs J MaddocksMs E ManningRegional Assessors in Obstetrics (England)East of EnglandMr B Lim FRCOG FRANZCOGEast Midlands, Yorkshire and Humber Miss HJ Mellows FRCOG (until 2008)Mr SF Spooner FRCOGMr D Tuffnell FRCOGProfessor J Walker MD FRCP FRCOGLondon and South EastMiss G Henson FRCOGMiss P Hurley FRCOGMiss C Iffland FRCOGDr K Morton FRCOGMr ME Setchell FRCS FRCOGMr GHW Ward FRCOG FRANZCOGNorth EastProfessor JM Davison MD FRCOGNorth West and West Midlands Miss P Buck FRCOG (until 2008)Mr SJ Duthie FRCOGMrs G Masson FRCOGMr DHA Redford FRCOGMr S Walkinshaw FRCOGSouth WestMiss I Montague MRCOGMiss S Sellers MD FRCOGRegional Assessors in Anaesthetics (England)East of EnglandEast Midlands, Yorkshire and HumberLondon and South EastNorth EastDr J Bamber FRCADr D Bogod FRCADr G Kesseler FFARCS (until 2008)Dr IF Russell FRCADr R Wilson MRCP FRCA (from 2008)Dr H Adams FRCADr W Aveling DRCOG FRCADr MB Dobson MRCP FRCADr I Findley DRCOG FRCADr S Yentis MD FRCADr D Hughes FRCANorth West and West Midlands Dr J Clift FRCA (from 2006)Dr K Grady FRCADr M Lewis FRCA (until 2007)Dr S Wheatly FRCADr A Wilkey FRCA (from 2007)South West Dr L Shutt FRCA (until 2007)Dr M Wee FRCA (from 2008)Regional Assessors in Pathology (England)East of EnglandEast Midlands, Yorkshire and HumberLondon and South EastNorth West and West MidlandsDr A Cluroe FRCPA Dip Forens PathDr LJR Brown FRCPathDr DR Morgan FRCPath (until 2008)Dr S Knight MRCPath (from 2006)Dr A Bates MD PhD MRCPathDr C Corbishley FRCPathDr M Hall FRCPathDr M Jarmulowicz FRCPathDr H Millward-Sadler FRCPath MHSM (until 2008)Dr R Hale FRCPathDr L Hammond PhD MRCPath (from 2007)Dr T Rollason FRCPath (until 2006)Dr G Wilson FRCPathDr A Yoong FRCPath (from 2007)200 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Appendix 3: Contributors to the Maternal Death Enquiry for the triennium 2006–08 and CMACE personnelNorth EastDr JN Bulmer PhD FRCPathSouth West Dr L Hirschowitz FRCPath (until 2008)Dr C Keen FRCPathDr J McCarthy FRCPath (from 2008)Regional Assessors in Midwifery (England)East of EnglandEast Midlands, Yorkshire and HumberLondon and South EastNorth EastMrs J Driver RN, RSCN, RM, ADM, SOM, PGCertSupervision of Midwives (from 2008)Miss J Fraser MSc DPSM RM RN (until 2008)Mrs JM Jackson RN RMMs J Lovett RGN RM (until 2006)Miss JM Savage RN RMMs D Watkins RN RM ADM MScMs P Cooke RM ADM MSc PGCEAMrs P Cox RM, RN, SOM (from 2008)Ms A Cuthbertson MSc RM RGN (until 2007)Ms C Drummond RGN RM (until 2007)Ms J Hughes RGN RM (from 2007)Ms D Phelan RM RN (from 2007)Ms S Sauter RM DNLS ADM Dip EthicsMs S Truttero MBA LLB ADM RN RM (until 2008)Ms A Weavers RMMs K Mannion RM RN ADM MScNorth West and West Midlands Ms D Birchall RGN RM LLB MSc (until 2007)Mrs S Brown RM RN (from 2008)Mrs H Jackson SRN SCM ADM BSc (Hons) (from 2008)Mrs E Newell RGN RM DPSM BSc (Hons)Ms N Parry RGN RM BScMs A Pedder RN RM BSc MA (until 2006)Mrs S Smithson BSc (Hons) RN ADM ONCSouth West Mrs V Beale RN RM Dip Man MSc (until 2006)Mrs J Drury RM RN MSc DpSM SEN (from 2006)Ms D Morrall RN RMMrs A Remmers RGN RM MScRegional Assessors in Psychiatry (England)East EnglandEast Midlands, Yorkshire and HumberLondon and South EastNorth EastNorth West and West MidlandsSouth WestDr F Blake MRCGP MRCPsychDr P Brownsett MRPsychDr S Shaw MRCPsych MMedSciDr A Gregoire DRCOG MRCPsychDr L McDonald MRCPsych MPhil Dip CBTDr A Walsh MRCP MRCPsychDr K Hofberg MMedSci(Psych) MRCPsychDr A Wieck MD FRCPsychDr S Oke MRCPsychOther UK nations (Northern Ireland, Scotland and Wales) and Ireland involved in the Maternal Death EnquiryNorthern IrelandDepartment of Health and Social Services:Dr C Willis MFPHNorthern Ireland (Health Promotion Agency)Obstetrics AssessorDr A Harper OBE MD FRCOG FRCPI FFSRHAnaesthetic AssessorDr D Hill FCARCSIPathology AssessorDr G McCusker FRCPathMidwifery AssessorMrs E Bannon RN RM MScPsychiatry AssessorDr J Lynch MRCPsychScotlandChairman of EnquiryClinical Adviser to Reproductive HealthProgramme, NHS Quality Improvement ScotlandDr J McClure FRCADr C Lennox FRCOGª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 201
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Volume 118, Supplement 1, March 201
Page 4 and 5:
AcknowledgementsSaving Mothers’ L
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AcknowledgementsAcknowledgementsCMA
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Forewordbeen written jointly by a m
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‘Top ten’ recommendationsServic
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‘Top ten’ recommendationscommun
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‘Top ten’ recommendationsof suc
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‘Top ten’ recommendationsMarch
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Oates et al.Back to basicsM Oates 1
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Oates et al.BreathlessnessBreathles
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Oates et al.appropriate pathway of
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LewisIntroduction: Aims, objectives
Page 26 and 27:
LewisAn important limitation of ran
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Lewismaternal and public health-pol
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Lewisresult in a live birth at any
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LewisChapter 1: The women who died
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Lewiswho would not have been identi
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Lewis1098Rate per 100 000 materniti
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LewisTable 1.4. Numbers and rates o
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Lewis2.50Rate per 100 000 materniti
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LewisTable 1.9. Number of maternal
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LewisTable 1.12. Numbers and percen
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LewisThere were cases where a major
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LewisBox 1.5. Classifications of Bo
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LewisTable 1.20. Number and estimat
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LewisNew countries of the European
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LewisTable 1.23. Direct and Indirec
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LewisTable 1.26. Characteristics* o
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Lewis4 Lewis G (ed). The Confidenti
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DrifeTable 2.1. Direct deaths from
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Drifewomen who died in 2006-08 had
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Drifedelivery she became breathless
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DrifePathological overviewFourteen
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NeilsonChapter 3: Pre-eclampsia and
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Neilsontrue, and what might be the
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NeilsonConclusionThe number of deat
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NormanBackgroundIn the UK, major ob
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Normanwhich there was catastrophic
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Normanrecommendations made in succe
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DawsonBox 5.1. The UK amniotic flui
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Dawsontry despite an extensive sear
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O’HerlihyTable 6.1. Numbers of Di
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O’Herlihytoxic shock syndrome aft
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HarperGroup A b-haemolytic streptoc
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Harperthe 6-week postnatal period,
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Harpera major intrapartum haemorrha
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HarperBox 7.1. Signs and symptoms o
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Harperwoman was given several litre
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Harper2 Lamagni TL, Efstratiou A, D
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LucasTable A7.1 Proposed new catego
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Lucasthe same infection scenario as
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McClure, CooperChapter 8: Anaesthes
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McClure, Cooperaddress, but protoco
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McClure, CooperPostpartum haemorrha
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McClure, CooperWorkloadA number of
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Nelson-PiercyTable 9.1. Indirect ma
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Nelson-Piercynary arteries. In view
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Nelson-Piercynormal left ventricle
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LucasAnnex 9.1. Pathological overvi
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Lucasdiac death that is non-ischaem
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de Swiet et al.causes but are aggra
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de Swiet et al.died of SUDEP before
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de Swiet et al.for 6 weeks after de
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de Swiet et al.mised. The obstetric
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de Swiet et al.CancerPregnancy does
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de Swiet et al.a thorough autopsy w
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Oates, CantwellChapter 11: Deaths f
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Oates, CantwellTable 11.1. Timing o
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Oates, CantwellTable 11.5. Maternal
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Oates, CantwellChild protection iss
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Oates, CantwellAll women who are su
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Oates, Cantwell4 Kendel RE, Chalmer
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Lewismaternal mortality rates or ra
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Annex 12.1. Domestic abuseAnnex 12.
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Annex 12.1. Domestic abuseshe could
Page 152 and 153: Garrod et al.supportive but challen
Page 154 and 155: Garrod et al.• Culture and system
Page 156 and 157: Garrod et al.the second stage and s
Page 158 and 159: Garrod et al.through the still heal
Page 160 and 161: ShakespeareChapter 14: General prac
Page 162 and 163: Shakespeareemergency caesarean sect
Page 164 and 165: ShakespeareCardiac diseaseDeaths fr
Page 166 and 167: Shakespearereduce the risks to the
Page 168 and 169: ShakespeareManaging a maternal deat
Page 170 and 171: Hulbertin the ED was of a high qual
Page 172 and 173: HulbertPre-eclampsia/eclampsia: lea
Page 174 and 175: HulbertTransfersWhen the obstetric
Page 176 and 177: Clutton-Brocksimply the case that s
Page 178 and 179: Clutton-BrockDiagnosis of sepsisTak
Page 180 and 181: Clutton-Brockpulseless electrical a
Page 182 and 183: Clutton-BrockImprovement Scotland (
Page 184 and 185: Lucas, Millward-Sadler95 mmHg. This
Page 186 and 187: Lucas, Millward-Sadleran agreed mai
Page 188 and 189: Annex 17.1. The main clinico-tholog
Page 190 and 191: MillerAppendix 1: The method of Enq
Page 192 and 193: MillerDatanotificationNotificationR
Page 194 and 195: Knight• investigating different m
Page 196 and 197: Knightbaseline incidence against wh
Page 198 and 199: LennoxAppendix 2B: Summary of Scott
Page 200 and 201: LennoxEvidence of effective managem
Page 204 and 205: Appendix 3: Contributors to the Mat
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6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

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