Improving the review of deaths

Sometimes babies die because of the quality of care mums receive. An enquiry in 2015 (MBRRACE-UK confidential enquiry into babies who died after 37 weeks of pregnancy before birth ‘antepartum term  stillbirths’) found that in 60% of cases, the stillbirth might have been prevented if health professionals had followed national guidelines. Although professional groups recommend that hospitals review what happened when a baby dies unexpectedly, the confidential enquiry found that only one in ten hospitals carried out a review and many of these were not good quality.

The 2016 Lancet Series: Ending Preventable Stillbirths  reported that a high proportion of stillbirths globally and in high-incomes countries like the UK could be avoided. But lessons about what went wrong are often overlooked and opportunities to improve care are missed. Sands believes every baby’s death - from 22 weeks’ gestation to 28 days of life - should be reviewed in a thorough way and include the views of parents

Key standards and data items for review were developed with a group of experts lead by Sands and the Department of Health between 2012 and 2015. A web-based tool to support good-quality hospital reviews is now being commissioned by the Health Quality Improvement Partnership (HQIP)

What Sands does

Sands called for maternity and neonatal units to use a standardised review process to understand events leading up to the death of a baby in our Preventing Baby’s Deaths Report in 2012

Sands and DH led the expert group which agreed what should be included in good-quality hospital reviews. The recommendations will form the basis for the new web-based tool currently being commissioned

Sands aim to ensure that Duty of Candour is upheld and that parents can share their experience as part of the review process