THE HISTORY OF CONFIDENTIAL ENQUIRIES

The current system of confidential enquiries started in 1952, just four years after the inception of the NHS. Before that, maternal deaths were reported to the Ministry of Health on an ad hoc basis.¹ The first report of CEMD covered 1952–54, capturing 77% of maternal deaths during that period. From 1985–87 onwards, a single report was published triennially for the whole of the United Kingdom.² The purposes of the CEMD were to assess the main causes of maternal deaths and, through the identification of avoidable causes, to reduce maternal morbidity and mortality by recommending improvements in clinical care and service provision; it also indicated directions for future research and audit.

CESDI was established in 1992, after the Department of Health directed that the 14 regions of England should undertake perinatal mortality surveys. CESDI’s remit was to improve understanding of the causes of death in late fetal life and infancy—that is, from 20 weeks post-conception to one year after birth. Its aim was to reduce mortality by identifying suboptimal patterns of practice and service provision related to those deaths and to make recommendations for improvement. Combining CEMD and CESDI, CEMACH retains this regional organisation and these overall aims.

There are two other national confidential enquiries: the National Confidential Enquiry into Perioperative Deaths (NCEPOD) and the Confidential …