Perinatal audit: does confidential enquiry have a place?

Medical audit is of growing importance. After a period of increasing interest in the profession in developing more systematic audit of clinical practice the subject has been highlighted as one of the central proposals in the Government’s white paper ‘Working for Patients’ (DH 1989); this proposal is one of few in the white paper to meet with immediate and full acceptance by the medical professional bodies. Confidential enquiry into deaths has figured more or less prominently in the better-known examples of medical audit to date, with particular emphasis on the scrutinizing of cases for instances in which clinical care might fall short of accepted standards. This approach was pioneered by the Confidcntial Enquiries into Maternal Mortality (DH 1989) which termed a ‘departure from the accepted standards . which may have played a part in the ensuing death’ an avoidable factor. Notably, this general method was also followed by the largest systematic review of deaths in this country, the Confidential Enquiry into Perioperative Deaths (Buck et al. 1988). Systematic regional perinatal mortality surveys are to be instituted by 1991, and the place of confidential enquiry into some categories of perinatal death is to be considered (Chalmers 1989). According to one’s point of view, it is either ironic or inevitable that the speciality which was first to introduce the notion of the avoidable factor in the audit of deaths should be the first to question seriously its basis, as applied to perinatal mortality. There seem to be three main interrelated objections concerning, respectively, the specification of accepted standards, the establishment of a causal link between an avoidable factor and the subsequent outcome, and the relative importance of a particular factor in the perhaps complex web of events preceding death. Firstly, the notion of accepted standards is undeniably rather loose: one person’s accepted standards may be no more than outdated ritual to another. It would be unrealistic to attempt to predefine a comprehensive set of responses appropriate to every circumstance which may arise in obstetric practice. Given that the accepted standards cannot be exhaustively itemized before the event, the objection then depends crucially on whether or not assessors can meaningfully determine departures from accepted standards after the event. Evidently those who conduct, participate in, and publish the various confidential enquiries believe that they can; this must include the great majority of obstetricians and gynaecologists who participate in enquiries into maternal mortality and perioperative deaths, and generally meet with approval rather than criticism for so doing (Black & McKee 1988). There seems no immediately apparent reason why obstetric practice in relation to perinatal mortality should constitute an exception. The second objection to the concept of the avoidable factor is that the existence of a direct causal link between a particular course of action and a subsequent death may not be sufficiently established to be convincing. When considering causation epidemiologically, a spectrum of strength of evidence may be recognized, ranging from the weak suggestion arising from association alone, through various degrees of inferential evidence, to the strong demonstration afforded by blind controlled intervention studies. One approach might be to accept a particular act of commission or omission as an avoidable factor only if suitably conducted double-blind randomized trials have shown it to result in a significantly higher probability of perinatal death. Whilst undoubtedly rational, this approach would suffer from some practical drawbacks. A large number of interventions have not yet been assessed in this way and, whilst