Researchers present recommendations for conducting standardised reviews when babies die

Published on Thursday, 14 December 2023 Post

The Perinatal Mortality Review Tool (PMRT) collaboration, co-led by Oxford Population Health's National Perinatal Epidemiology Unit, has today published their fifth set of findings and recommendations for hospitals and care providers who carry out reviews of the care received by babies who died in pregnancy from 22 weeks' gestation onwards or died within 28 days of being born (perinatal deaths).

This report presents the findings from 4,111 reviews completed from March 2022 to February 2023, coinciding with the third year of the global health emergency caused by the COVID-19 virus. Clinical services continued to be significantly challenged by the impact of the pandemic on pregnant women, staff sickness and shortages, and the start of the recent industrial action by health service staff. Despite this, there have been improvements in the use of the PMRT to carry out reviews of care when babies die.

Key findings:

• Over 95% of reviews identified areas for improvement and around 20% of the reviews identified at least one issue with care that may have made a difference to the outcome for the baby;
• For 84% of the reviews of neonatal deaths, a neonatologist was present for the review and in almost half of all reviews, an independent external panel member from a different trust or health board was present to provide a 'fresh eyes' perspective on the care received;
• In 95% of reviews conducted, the parents were asked for any comments they had about the care that they and their baby had received with parents having specific questions about what happened and why in 27% of reviews;
• Over 50% of the action plans for improvement were judged to be 'strong' or of intermediate strength indicating that increasing numbers of actions are system-level interventions designed to eliminate human error.

The report sets out key recommendations to be adopted by a range of stakeholders, including staff caring for bereaved parents, review teams, trusts and health boards, service commissioners and governments:

• Evaluate the approach to parent engagement and ensure that staff are trained and use the PMRT Parent Engagement materials, particularly in areas where fewer parents are engaged with the review process;
• Ensure that PMRT review teams are adequately resourced with administrative support and an independent external panel member;
• Use local PMRT summary reports and the national report to prioritise resources for the key aspects of care and quality improvement actions identified by reviews;
• Develop 'strong' action plans for improving care and audit their implementation and impact.

Professor Jenny Kurinczuk, Emeritus Professor of Perinatal Epidemiology at Oxford Population Health and PMRT collaboration lead, said 'While it is reassuring to know that the vast majority of baby deaths are now reviewed using the PMRT, the next consideration is the quality of the reviews that are carried out. One of the most important aspects of this is the quality of parent engagement in the review process so that parents can ask questions, give feedback, and express any concerns about their care that can be addressed as part of the review process. Starting in January 2024, the PMRT collaboration will offer online training sessions for review teams to supplement the written guidance available on the PMRT website, including a session on how to enhance and improve parent engagement.'

The PMRT review process was launched in early 2018 and has since been used to conduct over 23,000 reviews into perinatal deaths in the UK. The PMRT supports local review teams to conduct objective, robust, and standardised local reviews of care when babies die. This is to provide answers for bereaved parents and their families as to whether the care that they and their baby received was appropriately safe and personalised, and whether different care may have changed the outcome.

The PMRT review process also helps to guide improvements for care of all mothers and babies, reduce safety-related adverse events, and prevent future baby deaths. For around 90% of parents, the PMRT review process is likely to be the only hospital review of their baby's death that will take place.