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’. There are four aspects to the programme which are described below.
The PMRT was developed during 2017 and released in January 2018. Funded by the Department of Health (England) and the Scottish and Welsh Governments, the tool will be free to all NHS maternity and neonatal units in England, Wales and Scotland.
The PMRT tool is wholly integrated within the MBRRACE-UK programme of work.
The PMRT was designed and will be further developed with user and parent involvement to support high quality standardised perinatal reviews on the principle of ‘review once, review well’. The individuals involved in the development of the PMRT are listed below.
Members of the PMRT development working groups
Julie-Clare Becher - Consultant Neonatologist, Department of Neonatology, Royal Infirmary of Edinburgh, Edinburgh
Charlotte Bevan - Senior Research and Prevention Officer, Sands (stillbirth and neonatal death charity)
Thomas Boby - MBRRACE-UK/PMRT Senior Programmer, National Perinatal Epidemiology Unit, University of Oxford
Malli Chakraborty - Consultant in Neonatal Medicine, Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff
Katy Evans - Maternity Matron, Women and Children's Directorate Governance Lead, Taunton and Somerset NHS Foundation Trust, Taunton
Meg Evans - Consultant Perinatal Pathologist, Department of Pathology, Edinburgh Royal Infirmary, Edinburgh
David Field - Professor of Neonatal Medicine, Department of Health Sciences, University of Leicester, Leicester
Perinatal Programme Co-lead MBRRACE-UK
Charlotte Gibson - Consultant Midwife, King's College Hospital NHS Foundation Trust, London
Alex Heazell - Professor of Obstetrics and Director of the Tommy's Research Centre, University of Manchester, Manchester
Tracey Johnston - Consultant Obstetrician, Maternal and Fetal Medicine, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham
Sara Kenyon - Professor in Evidence Based Maternity Care, University of Birmingham, Birmingham
Jenny Kurinczuk - National Programme Lead MBRRACE-UK, Professor of Perinatal Epidemiology, Director, National Perinatal Epidemiology Unit, University of Oxford
Karen Luyt - Consultant Senior Lecturer in Neonatal Medicine, University of Bristol and University Hospitals of Bristol NHS Trust, Bristol
Kirsteen Mackay - Dr Kirsteen Mackay, Consultant Neonatologist, Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust
Helen McElroy - Consultant Neonatologist, Medway NHS Foundation Trust, Kent
David Millar - Consultant Neonatologist, Belfast Health and Social Care Trust, Belfast
Miguel Neves - MBRRACE-UK/PMRT Programmer, National Perinatal Epidemiology Unit, University of Oxford
Santosh Pattnayak - Consultant Neonatologist, Lead for Kent Neonatal Transport Service Medway NHS Foundation Trust, Kent
Sarah Prince - Clinical Fellow Perinatal Mortality Review Tool, Lindsay Stewart Centre for Audit and Clinical Informatics Royal College of Obstetricians and Gynaecologists
Coralie Rogers - Maternity Matron, Nottingham University Hospitals NHS Foundation Trust, Nottingham
Dimitrios Siassakos - Reader (Associate Professor) in Obstetrics at University College London and University College Hospital
Peter Smith - MBRRACE-UK/PMRT Programmer, National Perinatal Epidemiology Unit, University of Oxford
Claire Storey - PPI representative
Melanie Sutcliffe - Consultant Neonatologist, New Cross Hospital
The Royal Wolverhampton NHS Foundation Trust, Wolverhampton
Derek Tuffnell - Professor and Consultant Obstetrician and Gynaecologist, Bradford Teaching Hospitals NHS Foundation Trust
Jonathan Wyllie - Consultant Neonatologist, South Tees Hospitals NHS Foundation Trust, South Tees, Professor of Neonatology and Paediatrics, Durham University
The four aspects of the PMRT programme:
1. The PMRT tool
This aspect of the programme involves the iterative development, piloting, launch, maintenance and further development of the standardised perinatal mortality review tool (PMRT) across NHS maternity and neonatal units in England, Wales and Scotland. 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 clinical report for inclusion in the medical notes;
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 careto 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;
Other reports for use by the Child Death Review process and the PMRT will link with the soon to be commissioned National Child Mortality Database;
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.
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;
In production is a series of podcasts covering topics including getting to the root causes; the journey to improving multi-disciplinary perinatal review group activities; with more to follow.
3. Involvement of parents
The involvement of bereaved parents through:
The involvement of bereaved parents in the development of the PMRT;
Engagement with the MBRRACE-UK/PMRT 3rd sector stakeholder group;
On-going research: the findings of the PARENT II study led from the Universities of Bristol and Manchester will be incorporated into the design of the tool to ensure that the views of parents form part of the review of the death of their baby and that they are provided with information following the review in a meaningful way that meets their emotional and information needs.
As results from the PARENT II study emerge we will incorporate them into guidance and they will also be available on the PARENTS study website (open the 'PARENTS' section).
4. 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, an annual national report of the findings from the collected local reviews will be produced.
A parent and public friendly version of this report will also be made available.