The PMRT Tool

This aspect of the programme involves the iterative development, maintenance and further development of the standardised perinatal mortality review tool (PMRT) across NHS maternity and neonatal units in England, Wales, Scotland and Northern Ireland. The PMRT has been designed with user and parent involvement to support high quality standardised perinatal mortality reviews on the principle of 'review once, review well'. 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 technical clinical report for inclusion in the medical notes;

• From the technical clinical report staff should write a letter for parents which includes a meaningful, plain language explanation of the review findings, why their baby died and whether, with different actions, the death of their baby might have been prevented, which also answers any questions they have about their care and that of their baby;

• Summary reports generated from the tool enable the trusts/health boards and organisations 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 annual 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 an infographic summary of the main technical report is 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.

The national PMRT is 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 PMRT Form by email to: mbrracele@npeu.ox.ac.uk

Implementation support

Implementation support materials include:

• A 'Quick- start guide' to logging on and technical IT aspects of using the PMRT;
• A guidance document on conducting reviews and how to incorporate the PMRT into that process and the associated materials to support this;
• As series of slide sets to cover: the purpose of the PMRT; introducing the PMRT; identifying contributory factors and root cause analysis; developing action plans and sustained improvements; and further slide sets will follow;

National reporting

• To ensure that the lessons learned, the emerging themes and trends from local reviews are disseminated as widely as possible for the benefit of future babies, parents and families, annual national reports of the findings from the collected local reviews are produced.
• A parent and public friendly infographic from the annual report is also made available

Staff training

• To support local review panels in using the PMRT we are running a series of training sessions on line. Whilst on-line these are currently face-to-face.
• We are undertaking development of the training session to produce an on-line on-demand training programme which will enable staff to undertake the training in their own time at their own pace and repeatedly view modules. More news to follow.