Perinatal Mortality Review Tool

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, which is currently being developed, will be piloted over summer 2017 with the roll-out planned by the end of the year. The PMRT is being 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 to iteratively develop, pilot and facilitate the introduction of standardised perinatal mortality reviews across NHS maternity and neonatal units in England, Scotland and Wales. The tool will support:

  • Systematic, multidisciplinary, high quality reviews of the circumstances and care leading up to and surrounding each stillbirth and neonatal death;
  • 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.

Training materials to support the conduct of high quality reviews and the use of the tool to support the reviews will be developed and rolled out. Further details of the programme are available on the PMRT programme page.

The scope of the PMRT programme will encompass England, Wales and Scotland.

Duration of the programme: Following a competitive bidding process the contract for the PMRT process will run for three years until 31st January 2020.

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 to use.