Which perinatal deaths can we review using the PMRT?
The PMRT has been designed to support the review of the following perinatal deaths:
Late fetal losses where the baby is born between 22+0 and 23+6 weeks of pregnancy showing no signs of life, irrespective of when the death occurred, or if the gestation is not known, where the baby is over 500g;
All stillbirths where the baby is born from 24+0 weeks gestation showing no signs of life, or if the gestation is not known, where the baby is over 500g;
All neonatal deaths where the baby is born alive from 22+0 but dies up to 28 days after birth, or if the gestation is not known, where the baby is over 500g;
Post-neonatal deaths where the baby is born alive from 22+0 but dies after 28 days following neonatal care; the baby may be receiving planned palliative care elsewhere (including at home) when they die.
The PMRT is not designed to support the review of the following perinatal deaths:
Termination of pregnancy at any gestation;
Babies who die in the community 28 days after birth or later who have not received neonatal care;
Babies with brain injury who survive.
Which perinatal deaths should we review using the PMRT?
Trusts in England that are able to demonstrate compliance with the 10 actions announced by the Secretary of State in November 2017 will be entitled to at least a 10% reduction in their CNST maternity contribution. The first of these actions is to use the PMRT to review their perinatal deaths. This is part of the national work in England to achieve the Secretary of State's ambition to reduce the stillbirth and neonatal death rate by 50% by 2025.
How do we conduct a review when care was provided in more than one trust/health board?
To ensure that the whole pathway of care is reviewed and that parents receive a single coherent report the ideal is that a joint review is carried out by all the units involved in providing care for the mother and baby. The unit where the baby died is responsible for initiating the review.
We appreciate that organising joint meetings will be complex and not possible in all instances, but the use of video conferencing for joint discussions could be considered.
In the event that it is not possible to organise a joint review it is better that care is reviewed separately than not at all and that all units review the part of the care pathway they were involved in providing. As part of the PMRT development we will be making modifications to the PMRT to enable sharing of information across Units for review of the same case, although this facility is not yet available.
Do I need to report eligible cases to MBRRACE-UK as well as using the PMRT to review the same cases?
Yes, you should continue to report eligible cases for surveillance through the MBRRACE-UK online reporting system which is available on the MBRRACE website and then commence a review with the PMRT for relevant deaths.
There are differences between case eligibility for review and surveillance, so all deaths should be reported.
We are developing a case notification page which is common to both the MBRRACE-UK surveillance and the PMRT. This means that you will enter basic identifiable information and some details about the mother and her baby into the case notification section and then you can either then complete the surveillance information or start a review, or do both.
We are also developing the system so that the information common to both the MBRRACE-UK surveillance and the PMRT will automatically cross-populate each other. This will reduce duplication of effort. As soon as this function is available we will let you know.
Why do we need to report to MBRRACE-UK and use the PMRT?
The MBRRACE-UK online reporting form is a data collection tool for national surveillance. The PMRT has been designed as a review tool to assist units in completing a structured, standardised and thorough review; it is therefore important that both are used as they fulfil different functions.
How does the PMRT fit with Child Death Reviews?
The information included in the PMRT is being reviewed to ensure that it meets the requirements of the Child Death Review process in England for neonatal and post-neonatal deaths. As part of the development of the National Child Mortality Database for England, led by the University of Bristol, a mechanism is being developed to transfer PMRT reviews directly to the local Child Death Overview Panel (CDOP) to fulfil the requirements of the hospital review. This will avoid the need for staff to complete a separate form for the CDOP as is currently the case. The NCMD team in Bristol and the PMRT team are working with colleagues in Wales, Scotland and Northern Ireland to ensure future alignment with the Child Death Review processes in place or currently being developed.
How do I report to Each Baby Counts (EBC)?
The clinical review report (formerly technical report) can be downloaded from the PMRT as a PDF at the end of the review. This then needs to be anonymised, any additional information added if needed e.g. a timeline, before uploading to EBC via the online reporting system.
On the MBRRACE-UK case management screen, using the EBC 'button', you can list the deaths that are potentially eligible to be reported to EBC. It is also possible to log that a case has been reported to EBC.
How do I anonymise the PMRT report prior to uploading to EBC?
The PMRT clinical review reports need to be anonymised prior to uploading to EBC. Unfortunately it will never be possible for us to provide a copy of the clinical review report that is completely redacted, as the notes contained in the report may contain identifiers we cannot remove. There are several software tools that allow electronic redaction of PDFs; your local IT team may have something available for you to use. Alternatively you should print out the PDF and redact it by hand before scanning and uploading into the EBC reporting system.
Membership of the local PMRT review group
Who should be involved in our PMRT review group?
We strongly recommend that reviews are carried out by multidisciplinary groups. We have developed a recommended group composition which is listed in the PMRT guidance document. The guidance document is available on the PMRT implementation support page
Do we have to have an external member as part of the group?
We recommend that you involve an external member to provide a 'fresh pair of eyes' to the review of the care provided and to provide robust challenge where complacency or 'group think' in service provision, as identified in the Kirkup report, has crept in. By an external member we mean someone who is external to your Trust/Health Board with relevant clinical expertise.
We appreciate that there will be challenges organising the involvement of an external member which may include logistic and governance issues. You may want to consider identifying particularly difficult cases to discuss at a specific meeting when it is possible to invite an external member. Some trusts/health boards have addressed the governance issues and you may wish to consider how they have achieved this. Details from the North West Coast Strategic Clinical Network are presented in the implementation support slides '2_Introducing the Perinatal Mortality Review Tool'
Using the PMRT
We have identified additional 'issues' that are separate to those automatically generated by the tool what should we do?
The PMRT generates 'issues' based on the answers provided to the questions about the care provided. It then asks you to assess whether the issues contributed to the outcome and the underlying root cause to each one.
You may identify additional 'issues' that are not identified by the tool, you should use the 'add custom issue' feature to generate your own issues. You can create as many of these as is necessary.
How do we review multiple pregnancies when both/all the babies died?
At present a separate review for each baby will need to be carried out. We are developing the feature so that there will be an option to share the antenatal care details and review. When this feature is enabled the babies will be able to have a common antenatal review but separate intrapartum and postnatal reviews of care will still be required.
What is the purpose of the 'notes' function?
The white text boxes on the right hand side of the screen are sectioned by the elements of the review (antenatal, intrapartum etc.). These are text boxes into which notes about the case can be typed as the review takes place – similar to the type of notes you might make on paper as you undertake the review. This text will automatically be copied through to the final clinical report for you to edit. The boxes also serve as a place where good care can be recorded, although whether this should be included in the final report which is shared with parents should be considered on an individual basis.
We are having difficulty finding the contributory factor we want to allocate?
The contributory factors are included as a three stage drop down menu representing the three levels of the National Patient Safety Contributory Factors Classification Framework. You might find it helpful to print out the Framework in the table or fish bone format so that they can be looked at as a whole, separately during the meeting. This will make it easier to find the correct stem to identify the relevant contributory factors within the tool.
How do we save the review?
The PMRT automatically saves throughout the review process. The save status is displayed in the bottom right of the screen. Each case can be opened and amended as many times as needed prior to completion.
Once the review process is complete and the 'Complete Review' button is clicked the form is validated. If there are any validation errors you can correct them where appropriate and then accept any outstanding 'errors' by providing a reason to ignore them. Once validation is complete and the session is closed the clinical report generation is automatically started and the review can no longer be edited. You can however subsequently request for a review to be reopened by getting in touch with the PMRT team: email@example.com
Why is the review so long when we know the issue only occurred in one part of the care?
The PMRT is designed to review the whole pathway of care; this prevents pre-judging the reason why the baby died and therefore only reviewing some elements of care could lead to vital information being missed. We know from the confidential enquiry findings that significant issues are missed when only specific aspects of care are considered in isolation. It is also important to note that all reviews provide the potential to identify significant care deficiencies that, whilst they may not have contributed to this particular death, nevertheless need addressing.
What if the questions in the tool don't enable us to review the care properly?
There may be questions which we have omitted or responses to questions which don't include relevant answers. If you identify such omissions in the tool please let us know so that we can modify and improve the tool to meet your needs. You can do this within the PMRT using the 'contact us' function or email us via: firstname.lastname@example.org
How do I print the clinical review report?
The clinical review report can be printed once it has been 'Published' by pressing the 'Download' button. This will download a PDF file, which can be printed. We will shortly be adding the ability to print a draft report.
Reports generated by the PMRT
What should we give to the parents, the report seems very medical?
We are currently developing a parent-friendly version of the clinical report that is suitable for sharing with parents, as soon as this feature is available we will let you know. At this stage we suggest that you use the clinical report as the basis for the discussion with parents but that you write a letter for the parents' using appropriate language and ask the parents if they would like a copy of the clinical report explaining that this may be quite technical.
Can we have a summary of the cases that have been reviewed?
The PMRT will shortly enable registered users to specify a period of time and download a summary report that includes overall numbers of deaths reviewed in that period, the issues with care identified and actions required to improve future care. When this function is available it will enable staff to generate a report for the hospital board or directorate with whatever frequency is required. We will let you know when this function is available.
Will there be regional or national reports available?
We are developing regional and national reports; the format and timescales are currently still under discussion. The first national report is likely to be available in mid-2019 when the PMRT has been in use for a year.
How can we incorporate the PMRT within our governance process?
It is important to ensure that the PMRT forms part of the governance structure within your organisation. This can be supported by developing a standard operating procedure and sign off level requirements for particular deaths. Developing a relationship with your governance team is also important for identifying and ensuring that actions generated from the reviews are implemented and monitored.
How does the PMRT fit within the serious incident (SI) process?
If a stillbirth or neonatal death is identified through your hospital governance process as a serious incident (SI) then the completion of the PMRT will form a substantial part of an SI investigation. The PMRT will enable a thorough, structured review of the care provided. This may then need to be supplemented by further documentation as per the hospitals governance requirements to complete the SI investigation. This approach will avoid potential duplication of effort reviewing essentially the same information in a broadly similar process.
Can I upload case documents to use in the PMRT?
The PMRT does not have the facility to store case documents, although it will retain copies of the clinical review reports created using the tool.