This article describes the development of a database to facilitate quality assurance review of obstetric and neonatal care. The neonatal component of the database was developed as an alternative classification system to that of Wigglesworth's. The architecture of the new database follows that of the Winnipeg model, developed in part for the Pediatric Cardiac Surgery Inquest in Winnipeg, Manitoba. Use of the Winnipeg model allows reviewers to determine not only what happened and how, but more importantly, why. The new database provides a starting point for educational endeavors for all those involved in the care of patients, with the aim of preventing future deaths and other adverse outcomes.