1. Messages for anaesthetic care

2. Maternal deaths related to anaesthesia

3. Anaphylaxis

4. Anaphylaxis

5. Aspiration

6. Other women who died

7. Recurrent themes

8. Hypoventilation after extubation

9. Hypoventilation after extubation

10. Supine hypotension

11. Hypotension during spinal anaesthesia

12. Airway management

13. Planning care of women with complex needs

14. Insufficient planning or awareness

15. Insufficient planning or awareness

16. Insufficient planning or awareness

17. Team working, communication and escalation of care

18. Team working, communication and escalation of care

19. Team working, communication and escalation of care

20. Improving anaesthetic care

21. Improving anaesthetic care