Perinatal confidential enquiries
MBRRACE-UK conducts confidential enquiries of perinatal deaths and babies born with serious morbidities once every two years. The results of these enquiries are published in the perinatal confidential enquiry reports.
What is a confidential enquiry?
A confidential enquiry is a systematic process of expert, multidisciplinary review of cases occurring in a defined geographical area during a defined period of time. Confidential enquiries can include all cases which meet the enquiry criteria, or, if the number of cases is too large to review them all, a representative sample can be used for the enquiry as for MBRRACE-UK's perinatal confidential enquiries.
As indicated by the name, this process is entirely confidential and anonymous. Care is reviewed by a group of experts (called panel members) from hospitals across the UK and all reviewers are required to sign confidentiality agreements and disclose any conflicts of interest.
The aim of confidential enquiries is not to place blame, but to review the quality of the care provided and identify lessons that can help prevent future deaths or morbidities. To do this, care is reviewed against existing guidelines or best practices.
Topic choice
Topics for the perinatal confidential enquiry are proposed by clinicians, policy-makers, third sector organisations and members of the public in an open application process. The final topic is chosen by the MBRRACE-UK Independent Advisory Group.
The same organisations and individuals can propose multiple topics as long as they are suitable. Topics that are not suitable include those that require epidemiological studies to estimate the incidence and prevalence of a condition or investigate risk factors.
Previously selected perinatal confidential enquiry topics are shown below:
| Confidential enquiry topic | Start date | Publication date |
|---|---|---|
| Recently arrived migrant women with language difficulties (joint enquiry with the maternal programme) | 2023 | 2024 |
| Baby deaths to mothers of Black, Asian and White ethnicity | 2020 | 2023 |
| Stillbirths and neonatal deaths in twin pregnancies | 2018 | 2020 |
| Intrapartum stillbirths and intrapartum-related neonatal deaths (up to 28 days after birth) | 2016 | 2017 |
| Antepartum stillbirth in term normally formed infants | 2014 | 2015 |
| Congenital diaphragmatic hernia | 2013 | 2014 |
Identification of eligible deaths or morbidities
Perinatal deaths or babies with morbidities who are eligible for inclusion in perinatal confidential enquiries are identified through various means depending on the specific topic. When the selected topic is a subsection of perinatal deaths, these can be sampled directly from the MBRRACE-UK perinatal mortality surveillance data. In other instances, births and perinatal deaths can be identified using BAPS-CASS/UKOSS studies.
The number of babies included depends on the topic and the complexity of the care being reviewed. Once sampled, each baby's care is reviewed until there is a saturation of themes with no new messages for future care emerging.
Review of mothers' and babies' care
Topic Expert Group
Each perinatal confidential enquiry is steered by a multidisciplinary Topic Expert Group (TEG) that includes representatives from relevant clinical specialities and charities. Members of this group are selected through professional bodies based on expertise, experience and interest, and by submission of an application form. All members of the TEG are asked to sign confidentiality agreements prior to participation.
The TEG identifies the appropriate standards of care and guidance against which care should be assessed, and uses these to develop a series of questions and checklists to guide the panel members in their evaluations. These checklists facilitate a description of various risk factors and help to identify measurable aspects of the quality of care that should be routinely recorded in case notes.
Panel members
Panel members are selected from a multidisciplinary group of experts, including midwives, obstetricians, neonatologists and perinatal pathologists, to review the care received by the woman and her baby. All panel members participate in an online training session that covers confidentiality issues, use of the web-based note review system and an explanation of the enquiry process. They are all also required to sign confidentiality agreements and disclose any conflicts of interest.
Panel members are provided with documentation to guide the enquiry process including an evaluation form, a reference checklist, electronic links to the standards and guidance being used to assess the quality of care, and background information about the enquiry.
Review panel meetings
Panel members are given access to the medical records to review ahead of panel meetings. Each perinatal death is assigned to a lead panel member to review and present to the larger group. To facilitate an informed discussion panel, members are asked to review all deaths. After presentation and discussion, a consensus opinion is made on the quality of care provision. Any aspects of poor care or particularly good care identified are recorded and any themes are noted.
The number of deaths reviewed at each panel meeting varies depending on their length and complexity. To ensure standardisation across the confidential enquiry, each panel is chaired by a designated member of the MBRRACE-UK collaboration. An MBRRACE-UK clinical advisor also prepares a detailed synopsis for the meeting chair and completes the main checklist to provide additional contextual data for each baby's care.
Where there is no written information about an aspect of care, it is reported as not recorded. As in legal cases, MBRRACE-UK follows the principle that if there was nothing written in the notes then, in effect, it did not occur.
Classifying the quality of care
Each aspect of the care pathway is first assessed independently and graded using the criteria below:
- None: good quality care identified
- Minor: minor issues with the quality of care identified
- Significant: significant issues with the quality of care identified
- Major: major issues with the quality of care identified
As with the maternal confidential enquiries, panel members also agree a consensus opinion on the quality of care as a whole, according to the criteria below:
- Good care; no improvements identified
- Improvements in care identified which would have made no difference to the outcome
- Improvements in care identified which may have made a difference to the outcome
Often, this assessment of care is done separately for the mother and baby in order to determine the quality of care provision for each.
Identification of Cause for Concern
In all confidential enquiries conducted by MBRRACE-UK, assessors or panel members are also asked to identify whether any death should be flagged as a Cause for Concern for Communication to the Trust Medical Director and Healthcare Quality Improvement Partnership (HQIP). HQIP has a standard protocol for all the Clinical Outcome Review Programmes to escalate major concerns about care where it is clear these concerns have not been addressed at a local level.