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 five years of championing the need to establish good quality in-hospital reviews for when a baby dies, the government has finally commissioned a group to push the work forward.

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 developed 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 PARENTS1 and 2 studies, the British Association of Perinatal Medicine, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives.

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.

The new national Standardised Perinatal Review Tool (PMRT) will be available by the end of 2017 and will be free for units to use.

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