National review of baby deaths calls for stronger parent engagement, properly staffed review panels and action to improve care
Published on Thursday, 08 October 2026 Post
The latest annual report from the National Perinatal Mortality Review Tool (PMRT), delivered by the MBRRACE-UK/PMRT collaboration, has identified continuing opportunities to improve the quality of reviews carried out when babies die during pregnancy or soon after birth, and to translate learning from those reviews into safer care for mothers and babies.
The eighth annual report, Learning from Standardised Reviews When Babies Die, presents findings from 4,110 PMRT reviews completed across the UK between January and December 2025. Since the national PMRT was launched in early 2018, more than 34,000 reviews have been started.
The PMRT supports local teams to carry out robust, standardised reviews of care following late miscarriages, stillbirths and neonatal deaths. Its primary purpose is to provide bereaved parents and families with answers about the care they received, why their baby died and whether different care may have resulted in a different outcome. It also supports wider learning to prevent future baby deaths and improve care.
In 2025, a PMRT review was started for 97% of perinatal deaths across the UK, while reviews were completed and a final report produced for 87%. The report notes that this represents a major improvement since the PMRT was launched, while also showing that some families did not receive the benefit of a completed review.
Overall, review panels identified at least one issue with care in 93% of completed reviews. In 36% of reviews, at least one issue with care was judged by the review panel to have potentially been relevant to the outcome. Across reviews, 21% were holistically graded as having care issues that may have, or were likely to have, made a difference to the outcome for the baby.
The report finds that many of the most common issues with care have remained similar over time. These include late or absent booking for maternity care, inadequate fetal growth surveillance, management of reduced fetal movements, diagnosis and management of maternal medical, surgical and social problems during pregnancy, assessment of maternal risk and staffing during labour and birth, thermal and respiratory management of newborn babies, and the quality of neonatal documentation.
There were also areas of improvement. Smoking assessment and management issues reduced from 33% of reviews in 2018 to 12% in 2025, while issues relating to assessment and management of the need for antenatal aspirin fell from 17% to 4% over the same period.
Parents must remain central to reviews
The report emphasises that PMRT reviews are carried out primarily for bereaved parents. PMRT data indicate that 96% of parents were told that a review would take place and, among those parents, 96% were reported as having been invited to provide questions and comments about their care.
The report recommends maximising parent engagement by ensuring parents are approached respectfully, staff are trained to listen with compassion and empathy, and parents are enabled to provide their perspectives and questions. It stresses that meaningful engagement means explaining the review, seeking parents' views and questions, and providing verbal and written feedback about the findings - not requiring parents to attend the review meeting.
Multidisciplinary review and independent challenge
The report says multidisciplinary review is essential. Review teams have become larger and more multidisciplinary since 2018, but gaps remain. In 2025, 86% of neonatal death reviews included a neonatologist or paediatrician and 70% included a neonatal nurse. Only 35% of reviews had administrative support, while around 82% included a member of a risk management or governance team.
The report also recommends adequate resources and support to enable independent senior external clinicians to participate in multidisciplinary PMRT review meetings, providing objective challenge and a 'fresh eyes' perspective.
From review findings to stronger action
Across the 4,110 completed reviews, review teams recorded actions intended to improve future care. Analysis presented in the report shows that 52% of sampled actions were classified as weak, 39% as intermediate and 9% as strong. The report notes that not every issue requires a strong action, but stresses the importance of system-level action and oversight of whether action plans are implemented.
The 2026 report sets out six recommendations covering parent engagement; adequate staffing of review panels; inclusion of PMRT responsibilities in consultant job plans and other relevant roles; participation of independent senior external clinicians; compliance with PMRT best practice standards and training; and use of local and national PMRT findings, alongside MBRRACE-UK real-time monitoring data, to prioritise resources for quality improvement.
Carrying out a review when a baby has died during pregnancy or soon after birth is part of the final aspect of care maternity and neonatal services need to provide. It's essential that reviews are done well and that parents are invited to engage with the process, so they can ask questions and provide comments about their care which are addressed in the review. The grading of care information from this report indicates that about 1 in 5 baby deaths were potentially avoidable had different care been given.
The trend data also highlights that the same issues with care are repeatedly identified indicating where service improvement activities need to focus. Finally, the quality of the reviews themselves will be improved with the right clinical team members present, for example ensuring that all neonatal death reviews involve neonatologist/paediatricians and neonatal nurse; and ensuring that at least one external senior clinician is present for the MDT discussion. Carrying out good quality local PMRT reviews has the capacity to improve care for all mother, babies and families, and to prevent future baby deaths.
Emeritus Professor Jenny Kurinczuk, PMRT National Programme
Full Report
Link to full report: www.npeu.ox.ac.uk/pmrt
Further Information
For further media information, please contact Rob Phillips, Communications Manager at the Nuffield Department of Women's & Reproductive Health, University of Oxford, on rob.phillips@wrh.ox.ac.uk or 07730 527341.
About the Perinatal Mortality Review Tool (PMRT)
The PMRT was launched in England, Wales and Scotland in 2018 and in Northern Ireland in 2019 to support high-quality reviews of care when babies die during pregnancy or soon after birth. It supports reviews from 22 weeks' gestation onwards, including late miscarriages, stillbirths and neonatal deaths.
The Perinatal Mortality Review Tool is delivered by the MBRRACE-UK/PMRT collaboration and is based within the National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Women's & Reproductive Health, University of Oxford.
About NPEU
The National Perinatal Epidemiology Unit (NPEU) is based within the Nuffield Department of Women's & Reproductive Health at the University of Oxford, established in 1978. Its work has a strong focus on improving the health and care of women, babies and families by generating evidence that can inform clinical practice, health services and policy.
The NPEU is home to major national programmes concerned with maternity, perinatal and neonatal care, including the Perinatal Mortality Review Tool (PMRT). Through the PMRT, the Unit supports a standardised approach to local reviews when babies die during pregnancy or soon after birth, helping services answer parents' questions, identify learning from care and use that learning to improve care for mothers, babies and families.
More information about the NPEU is available at www.npeu.ox.ac.uk
About the Nuffield Department of Women's & Reproductive Health, University of Oxford
The Nuffield Department of Women's & Reproductive Health (NDWRH) at the University of Oxford is a world-leading institution driving transformative research in women's health, reproduction, and conservation science. With a legacy of excellence since 1937, NDWRH is globally recognised for its pioneering contributions to medical research, clinical practice, and postgraduate education.
Its mission is to shape a future where high-quality, evidence-based healthcare is accessible to all, leading to improved health outcomes worldwide. Through innovative research and teaching, we are committed to advancing healthcare standards and promoting global progress in reproductive health.
To learn more about research, education and clinical studies, please visit www.wrh.ox.ac.uk
