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Perinatal Mortality Review Tool

PMRT fifth annual report – December 2023

Learning from Standardised Reviews when Babies Die

The MBRRACE-UK/PMRT collaboration is pleased to announce the publication of the fifth annual report of findings from the reviews completed using the National Perinatal Mortality Review Tool (PMRT) from March 2022 to February 2023. The main report, technical paper, tables of findings, infographic and summary of the recent staff survey use of parent engagement materials are available to download from the reports page.

Slides from the dissemination and engagement meeting presenting the report findings are also available to download on the report page.

The national PMRT is now live and available for use by Trusts and Health Boards

All staff requiring access to use the PMRT need to be authorised to do so, even if they are already registered to use the MBRRACE-UK system.

Authorisation for access is via completion and return of the authorisation form

by email to:

A collaboration led by MBRRACE-UK has been appointed by the Healthcare Quality Improvement Partnership (HQIP) to develop and establish a national standardised Perinatal Mortality Review Tool (PMRT) building on the work of the DH/Sands Perinatal Mortality Review 'Task and Finish Group'. The PMRT has been designed with user and parent involvement to support high quality standardised perinatal reviews on the principle of 'review once, review well'.

The aim of the PMRT programme is introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units in England, Scotland and Wales. The tool supports:

  • Systematic, multidisciplinary, high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death, and the deaths of babies who die in the post-neonatal period having received neonatal care;
  • Active communication with parents to ensure they are told that a review of their care and that of their baby will be carried out and how they can contribute to the process;
  • A structured process of review, learning, reporting and actions to improve future care;
  • Coming to a clear understanding of why each baby died, accepting that this may not always be possible even when full clinical investigations have been undertaken; this will involve a grading of the care provided;
  • Production of a report for parents which includes a meaningful, plain English explanation of why their baby died and whether, with different actions, the death of their baby might have been prevented;
  • Other reports from the tool which will enable organisations providing and commissioning care to identify emerging themes across a number of deaths to support learning and changes in the delivery and commissioning of care to improve future care and prevent the future deaths which are avoidable;
  • Production of national reports of the themes and trends associated with perinatal deaths to enable national lessons to be learned from the nation-wide system of reviews.
  • Parents whose baby has died have the greatest interest of all in the review of their baby's death. Alongside the national annual reports a lay summary of the main technical report will be written specifically for families and the wider public. This will help local NHS services and baby loss charities to help parents engage with the local review process and improvements in care.

Implementation support materials are available to support the conduct of high quality reviews and the use of the PMRT. Further details of the programme are available on the PMRT programme page.

The scope of the PMRT encompasses England, Wales and Scotland.

Duration of the programme: Following a competitive bidding process the contract for the PMRT programme initially ran for three years until 31st January 2020, and after a successful extension application will now continue to 30th September 2021.

Funding: The PMRT programme has been commissioned by HQIP on behalf of the Department of Health (England) and the Welsh and Scottish Governments; as a consequence the tool will be free for use by Trusts and Health Boards in England, Wales and Scotland.

Updated: Friday, 15 December 2023 09:12 (v33)