Frequently Asked Questions

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These FAQs address:

Reviewing
Reporting
Membership of the local PMRT review group
Using the PMRT
Reports generated by the PMRT
Governance

If you have a question which is not addressed here or in the Guidance documentation please contact us either using the 'contact us' facility within the tool or by emailing us at: mbrrace.support@npeu.ox.ac.uk

Reviewing

Which perinatal deaths can we review using the PMRT?

Late fetal losses (also called late miscarriages) 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 weeks of pregnancy 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.

Which perinatal deaths should we not use the PMRT to review?

Termination of pregnancy at any gestation;
Babies who die in the community up to 28 days after birth or later who have not received neonatal care;
Babies with brain injury who survive.

Trusts in England should refer to the Maternity Incentive Scheme (MIS) being run by NHS Resolution to check the requirements of reviewing which are included in Safety Action 1.

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 a single coherent report of the review findings is generated 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 PMRT review.
We appreciate that organising joint meetings may 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. To support this the 'assignment' feature is part of the PMRT. Assignment allow the unit initiating the review to 'assign' the review to the other unit(s) involved in care to enable them to review the care they provided. Following their review, they reassign the PMRT back to unit which initiated the review. This also ensure that any issues with care are 'owned' by the unit that generates them and importantly a single report coherent report is generated for discussion at the follow-up meeting with parents.

Reporting

Do I need to report eligible cases to MBRRACE-UK as well as using the PMRT to review the same cases?

Yes, you should report eligible deaths for surveillance through the MBRRACE-UK online reporting system. This is available on theMBRRACE website and then commence a review with the PMRT for relevant deaths.
There are differences between deaths eligibility for review and surveillance, so all deaths should be reported.
A certain amount of the information common to both the MBRRACE-UK surveillance and the PMRT will automatically cross-populate from the MBRRACE-UK surveillance to the PMRT, but not vice versa. To further reduce duplication of effort we are extending this cross-population.

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 of the whole pathway of care; it is therefore important that both are used as they fulfil different functions.

Recommended composition of the PMRT review team

Who should be involved in our PMRT review group?

PMRT reviews must be 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. We have also created a team infographic which you can see above or download here.
To be multidisciplinary, the team conducting the review should include at least one and preferably two of each of the professionals involved in the care of pregnant women and their babies. Ideally the team should also include an external member (see below).
Bereavement care staff (midwives and nurses) should form part of the review team to provide their expertise in reviewing the bereavement and follow-up care, and advocate for the parents. Unless they have been specifically employed to do so, it should not be the responsibility of bereavement care staff to run the reviews, chair the panels nor provide administrative support.

Do we have to have an external member as part of the group?

Ideally, the multi-disciplinary review team should include an external member.
An external panel member should be a relevant senior clinician who works in a hospital external to the trust/health board undertaking the review and external to any trust/health board involved in the care at any stage. Their role is to be present at the review panel and actively participate in the review to provide a 'fresh eyes', independent and robust view of the care provided. This may involve challenging the care that was provided where complacency or 'group think' in service provision, as identified in the Kirkup Morecambe Bay Inquiry report, has crept in. The external should be from a relevant speciality and be senior enough to provide challenge where appropriate and should actively participate in the discussions about the care.
If more than one Trust is involved in the review, because more than one Trust was involved in the care, none of these staff members are 'external' panel members because they do not provide an independent view of the care. They should not be listed as 'external' members in the participant list.
Although the MNVP member in England may not be employed directly by the Trust they should not be regarded as, nor documented as, an 'external' member. They are present to represent the wider parent voice.
To ensure that external members of the review panel are identified as such the 'participant' feature in the PMRT system has been modified so that this is clear.
See our MIS FAQs page for more details of how to identify external participants.
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 of the babies died?

At present a separate review for each baby will need to be carried out. We will in the future develop a 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 care 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. Note that if the review is complete and the report 'published' but then reopened and re-reviewed new notes will not be saved.

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. The review for each baby 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: mbrrace.support@npeu.ox.ac.uk

Why is the review so long when we know the issue only occurred in one part of the care?

The PMRT was specifically designed to support the review of the whole pathway of care; this prevents pre-judging the reason why the baby died and therefore only reviewing some elements of care which could lead to vital information being missed. We know from the confidential enquiry findings that significant issues with care 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 issues with care that, whilst they may not have contributed to this particular death, nevertheless need addressing to improve care for all women and babies.

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: mbrrace.support@npeu.ox.ac.uk

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. You are also able to print your draft report by clicking on Download.

Reports generated by the PMRT

What should we give to the parents, as the report seems very medical?

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 after you have met with them for their follow-up appointment. You can 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 enables 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.

Will there be reports available?

There are national annual reports available and we provide updated reports each year, exploring national data. To see our reports, click here.

Governance

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. We strongly recommend that your multidisciplinary team includes members from you risk and governance team.

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 additional documents, although it will retain copies of the clinical review reports created using the tool.