• Margaret Jackson.
• York Teaching Hospitals NHS Foundation Trust.
• Pract Midwife. 2011 Apr 1;14(4):19-20.

AbstractMaternity Services and the whole team delivering care to women and their families have had the benefit of the review and recommendations from the confidential enquiries into maternal deaths since their beginnings in 1952. The maternal death enquiry continued to develop and became UK wide in the 1990s. The title of the report published in December 2007 changed to the more positive 'Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer--2003-2005'. Midwives must be aware of the report, the findings reached and recommendations made. They must ensure that their own knowledge and clinical practice are up to date. The most recent report has just been published in March 2011. It is an ideal opportunity for midwives to be involved and work with the whole team to review the report and its recommendations. They can contribute towards ensuring that the local service and care delivered meet the standards expected, reflect the recommendations and make the service provided for local mothers and babies as safe as possible. In this article, a supervisor of midwives and regional midwifery assessor reflects on these role in relation to maternal death and the lessons that can be learnt from the actions taken and recorded in each case when this devastating event occurs.

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