Learning from Standardised Reviews When Babies Die: National Perinatal Mortality Review Tool - Third Annual Report (October 2021)

Summary

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 to support standardised perinatal mortality reviews across NHS maternity and neonatal units.

Unlike other reviews 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 3,981 reviews which were completed between March 2020 and February 2021.

Content

The report makes several recommendations including:

1. Provide adequate resourcing for multidisciplinary PMRT review teams, including administrative support. Ensure the involvement of independent external members in the team.
   Action: Trusts and Health Boards, regional/network support systems and organisations, Service Commissioners
2. Use the PMRT parent engagement materials to support engaging parents and families in the review process, including making them aware a review is taking place and giving them flexible opportunities at different stages to discuss their views, ask questions and express any concerns. Many parents may want to give positive feedback about the care they received.
   Action: Trusts and Health Boards, staff caring for bereaved parents, Service Commissioners
3. Use the local PMRT summary reports and this national report as the basis to prioritise resources for key aspects of care and quality improvement activities identified as requiring action.
   Action: Trusts and Health Boards, Service Commissioners, regional/network support systems, Governments
4. Improve the quality of recommendations developed as a consequence of reviews by developing 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