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 has long campaigned for baby’s death - from 22 weeks’ gestation to 28 days of life – to be reviewed in a thorough way and to include the views of parents, whose view of care, as the people at the centre of it, is often unique

Key standards and data items for review were developed with a group of experts lead by Sands and the Department of Health (DH) between 2012 and 2015. It was as a result of this work that on behalf of the DH, the Health Quality Improvement Partnership (HQIP) commissioned in 2016 a web-based tool to support good-quality hospital reviews.

What Sands does

Sands is thrilled that after six years of championing the need to establish good quality in-hospital reviews for when a baby dies, the government has funded a new standardised Perinatal Mortality Review Tool or PMRT.

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 is directly involved in the development of the tool which is run by a collaboration led by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK), which includes representatives from Sands, the PARENTS study in Bristol and Manchester, the British Association of Perinatal Medicine, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.

The work comes directly out of the Sands/DH led expert group which agreed what should be included in good-quality hospital reviews. Sands aim is to ensure that Duty of Candour is upheld and that parents can share their experience as part of the review process, as well as receive feedback about the results of the review. To see why it's important to offer parents the opportunity to share their views and questions as part of review see Sands presentation.

The new national Perinatal Mortality Review Tool (PMRT) is available in England, Scotland and Wales and is free to use.
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