The national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units
Unlike other review or investigation processes, the PMRT makes it possible to review every baby death, after 22 weeks’ gestation, and not just a subset of deaths.
This report presents data from the 3,693 reviews which were completed between March 2019 and February 2020.
The report sets out several recommendations including:
1.Improve the engagement of parents in reviews by standardising and resourcing local processes to ensure all bereaved parents are told a review will take place and have ample opportunities at different stages to discuss their views, ask questions and express any concerns as well as positive feedback they have about the care they received.
Action: Trusts and Health Boards, staff caring for bereaved parents
2.Provide adequate resourcing of multidisciplinary PMRT review teams, including administrative support.
Action: Trusts and Health Boards, Service Commissioners
3.Improve the process of PMRT review by involving sufficient members of multidisciplinary internal staff and an external member as part of the PMRT review team.
Action: Trusts and Health Boards, regional support systems and organisations e.g. Local Mater nity Systems in England, Service Commissioners
4.Improve the quality of service improvements as a consequence of reviews by developing ‘strong’ actions targeted at system level changes and audit their implementation and impact.
Action: PMRT review teams, governance teams in Trusts and Health Boards, Service Commissioners
5.Use the local PMRT summary reports and this national report as the basis to prioritise resources towards key aspects of care identified as requiring action.
Action: Trusts and Health Boards, Service Commissioners, regional support systems, e.g.
6.Local Maternity Systems in England, Governments and national service organisations Conduct research into new interventions that may be required to address issues with care identified in the PMRT report.
Action: Research funding organisations and researchers