National Maternity Review, England, 2015

An independent review of maternity services in England was commissioned and carried out in 2015 to:

  • look at how maternity services need to change
  • make sure that all maternity services can learn from the deaths at Morecambe Bay NHS Trust in Cumbria

Sands joined the review panel in the final four months. We asked the panel to listen to the experiences and views of bereaved parents as we did not believe they were being heard. Around 50 bereaved parents attended half-day sessions in Manchester and London and around 1,200 bereaved parents completed a survey asking about their experiences.

The feedback from parents whose babies had died directly influenced the final report, Better Births.

What Sands does

As a member of the Maternity Review panel we argued for safety to be prominent in the Better Births report

We facilitated the engagement sessions with bereaved parents and designed the dedicated online survey


Involving parents in hospital reviews of their baby’s death

Sands is clear that every time a baby dies, the hospital should carry out a thorough review of what happened before and after a baby’s death to identify areas for improvement. Parents should be offered the opportunity to take part in this review, with flexibility about how and when they are involved

We ran a survey in June 2016 to find out what parents think about being involved in reviews. Almost 300 parents responded.

We combined the survey results with work done by the Bristol University PARENTS research team to come up with ‘top tips’ for hospital staff carrying out reviews. The top tips are included in the Each Baby Counts report 2016.

Top tips for involving parents in perinatal mortality reviews

  1. Parents are not aware of perinatal review – either that their baby’s death was or should have been reviewed.
  2. Parents want to know about the outcomes of the review of their baby’s death.
  3. Most parents want to contribute their perspective to the review process BUT some do not and only want to know about the outcomes. Assumptions should not be made as to what individual parents want.
  4. Parents want to be able raise questions for the review to address
  5. Parents want flexibility on the timing of WHEN they contribute to the review process.
  6. Parents want flexibility on HOW they contribute their version of   what happened, including in a meeting or a written account, which may be free text or with some guidance.
  7. Parents want the review to look at their clinical AND emotional care.
  8. Parents want to use the review to give negative and positive feedback on their care.
  9. Parents want the review to cover the whole pathway of care, both antenatal and postnatal, with input from community healthcare professionals.

National Bereavement Care Pathway

Sands are working to produce a National Bereavement Care Pathway in collaboration with other charities and with the support of the Department of Health and the All Party Parliamentary Group on Baby Loss. 

What Sands does

We have presented the survey results at national conferences of health professionals and policy makers.

The survey results will be used in developing a new tool to improve hospital reviews of baby deaths.