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PMRT Implementation Support

This page provides resources to support the implementation and use of the PMRT.

Other resources are also available when you log on to use the PMRT.

If you have any questions you can consult the FAQ page

The following resources are available on this page:

Guidance for using the PMRT

We recommend that you read the guidance for using the PMRT before you start your review process and keep it handy to consult. If you have any questions which are not dealt with here or on the FAQ page please contact us by either using the 'contact us' function with the PMRT itself or emailing us at:

Perinatal mortality review meeting terms of reference template

We recommend that you develop terms of reference for your perinatal mortality review group. You can base these on the template we have developed.

National Patient Safety Agency (NPSA) Contributory Factors Classification Framework

As part of the process of review you will be asked to classify the factors which have contributed to each of the issues with care your review has identified using the NPSA Contributory Factors Classification Framework. For ease of reference during your review meetings we recommend that you download and print out copies of the Framework.

Slide sets

The slides sets below are available for use and circulation by staff in Trusts and Health Boards.

Please feel free to download the slide sets which can be presented in their current format. Alternatively you can 'pick and mix' from the sets to create your own slide presentation which can include your own Trust/Health Board materials.

The existing slide sets and any presentations you create can be used and circulated to colleagues in your Trust/Health Board and placed on your Trust/Health Board website for staff if that is helpful.

1_Purpose of the perinatal mortality review tool

2_Introducing the perinatal mortality review tool

3_Identifying contributory factors and root cause analysis

4_Action plans and sustained improvement


“Finding the Root Cause – Missed IUGR despite Scanning”

This podcast illustrates how to address contributory factors that are identified at perinatal mortality review. The podcast focuses on the area of fetal growth scans in cases where small for gestational age (IUGR) has not been identified antenatally despite scanning, detailing the key elements that should be reviewed, how to do this and how to work in a multidisciplinary collaborative way. Featuring a maternal-fetal medicine consultant and a lead sonographer, examples of cases of missed IUGR are discussed that highlight the range of causes and how different strategies are needed to address them effectively.

Whilst this podcast focuses on growth scans the key messages can be applied to finding the root cause in any area: carrying out a structured review, not jumping to conclusions and identifying the key causes. Improvements in care can only be made if we understand the root cause of why things went wrong, which then allows appropriate interventions to be implemented. In addition to learning from deaths, parents deserve to know why their baby died and how any failings in care will be addressed, this podcast it intended to help units in developing their approach to answering these questions.

“Perinatal Mortality Reviews - Journey of Improvement”

This video outlines the journey that one hospital has been on to improve their perinatal review process prior to the introduction of the PMRT. It identifies the challenges their original meetings faced in ensuring robust, standardised reviews of the whole pathway of care for each perinatal death. The journey they have been on to improve the process, how they have engaged clinicians and the need to prepare well in advance to maximise the time for discussion within the meeting. Practical tips from what they have learnt are discussed and can be applied to other units developing their own review group alongside areas for future development such as parental engagement. We hope that this video resource will encourage other hospitals on their journey to improve their local reviews whilst implementing the PMRT.

Further resources will follow.

If you have any questions please email:

Updated: Friday, 25 September 2020 11:27 (v15)