Researchers present recommendations for conducting standardised reviews when babies die

Published on Thursday, 12 December 2024 Post

The Perinatal Mortality Review Tool (PMRT) collaboration, co-led by Oxford Population Health's National Perinatal Epidemiology Unit, has today published their sixth 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 4,311 reviews completed from January 2023 to December 2023. During this year, UK clinical services and healthcare providers faced significant challenges including staff shortages and industrial action. Despite this, there were continued improvements in the use of the PMRT to carry out reviews of care when babies die.

Key findings:

• During 2023, a review of care was started for 98% of all babies who died in the perinatal period and 96% of babies who died in the neonatal period (within 28 days of being born). While overall only 88% of reviews were completed, the proportion of reviews that were completed has increased since the launch of the tool;
• Over 93% of reviews identified areas for improvement and 34% of reviews identified at least one issue with care that may have made a difference to the outcome for the baby;
• Having an external panel member present for the review, who is able to provide a 'fresh eyes' independent challenge has increased from 45% of reviews in 2022 to 51% in 2023;
• Having a neonatologist or paediatrician present for reviews of neonatal deaths has remained stable at 84%, having increased from 59% in 2021-2022;
• Parents were invited to provide comments or questions about their care in 96% of instances and 55% of parents had specific questions about what had happened and why;
• The most common issue with care identified during the antenatal period was late booking or being un-booked for care, which was identified in 30% of reviews;
• The most common issue identified during labour and birth was maternal monitoring in labour, which was identified in 22% of reviews;
• The proportion of action plans that were described as 'strong' and 'intermediate' increased slightly from 51% in 2022 to 54% in 2023.

The report sets out five key recommendations for 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 in reviews, ensure staff are trained and use the available PMRT Parent Engagement materials, particularly in trusts and health boards where fewer parents are engaged with the review process;
• Provide adequate resourcing of PMRT review teams, including administrative support, and risk and governance team members;
• Provide adequate resourcing to ensure the involvement of independent external clinicians in review teams;
• Use the local PMRT summary reports and this national report as the basis to prioritise resources for key aspects of care and quality improvement activities identified as requiring action;
• Improve service quality improvement activities implemented as a consequence of reviews by developing 'strong' actions targeted at system level changes and audit their implementation and impact. Review and implement relevant examples of 'strong' quality improvement activities in this report to improve service delivery.

Dr Adele Krusche, PMRT researcher at the National Perinatal Epidemiology Unit, said:

While it is reassuring that the vast majority of perinatal deaths are now reviewed using the PMRT and that the majority of parents are able to provide comments and ask questions, it is equally important to focus on continuing to improve on the involvement of neonatologists and paediatricians when a neonatal death is reviewed.

Professor Jenny Kurinczuk, PMRT National Programme Lead, said:

From a survey of quality improvements activities we conducted this year it is heartening to see so many examples of excellent quality improvements in care instigated following PMRT findings. It is also encouraging to see an increase in the proportion of reviews where an external member was present. External specialists are there at the review to provide a 'fresh eyes' independent perspective and challenge to the care provided. We know that parents in particular find it reassuring when an external specialist is present for their review.

Since it was launched in 2018, all trusts and health boards across England, Wales, Scotland and Northern Ireland have adopted the PMRT and by 17 October 2024 over 27,000 reviews had been started and/or completed using the tool. 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 findings also help to guide improvements in care of all mothers and babies, reduce safety-related adverse events, and prevent future baby deaths. For the majority of bereaved parents, the PMRT review process is likely to be the only review of their baby's death that will take place.

The PMRT is funded in England by the Department of Health and Social Care (DHSC) and commissioned by the DHSC on behalf of NHS Wales, the Health and Social Care Division of the Scottish Government, and the Northern Ireland Department of Health.

The MBRRACE-UK collaboration has also today published the results of a confidential enquiry into the care of women of recent migrant women with language barriers who have experienced a stillbirth or neonatal death.