In order to reduce the rate of babies dying in the UK, it is vital that we review when things got wrong. We are involved in a number of projects to improve the ways lessons are learnt after the death of a baby.

Each Baby Counts 

Each Baby Counts collects information about every baby in the UK who dies or is seriously brain injured during birth. This information comes from the hospital’s review of what happened. By collecting and assessing the information from all hospitals, the Each Baby Counts team can see if these incidents have things in common. If they do, the team can call for better funding and guidance to help hospitals improve safety on labour wards.

Each Baby Counts is run by the Royal College of Obstetricians and Gynaecologists and aims to reduce such tragedies by half by 2020

It is hoped that Each Baby Counts will eventually be widened to include more babies who die before, during or shortly after birth

Read the Each Baby Counts progress report, published in June 2016.

It is hoped that Each Baby Counts will eventually be widened to include more babies who die before, during or shortly after birth.

For more information on Each Baby Counts, go to www.rcog.org.uk/eachbabycounts


What Sands Does

Sands is a member of the Independent Advisory Group for Each Baby Counts, ensuring parents’ views are heard.

We wrote a section on involving parents in the review of their baby’s care for the 2016 progress report and which we presented at the report launch.

Perinatal Mortality Review Tool

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.
For more information go to: https://www.npeu.ox.ac.uk/pmrt

Download "Role of parents in reviews" presentation here

Engaging parents in review

Letters to engage parents in the Perinatal Mortality Review process

The following letter templates have been designed to help healthcare professionals to engage parents in the Perinatal Mortality Review process, in conjunction with the use of the Perinatal Mortality Review Tool (PMRT). The letters were developed by a subgroup of the Sands/Department of Health Task and Finish Group to standardise perinatal mortality review and have been updated by the National Bereavement Care Pathway Parent Advisory Group. 

The first template is for parents whose baby died before birth, the second for parents whose baby died during or after birth.

Open Letter for parents engaging them in review (PMRT) – deaths before birth configuration options

Letter for parents engaging them in review (PMRT) – deaths before birth

This template is designed to engage parents whose baby died before birth, in conjunction with the use of the Perinatal Mortality Review Tool (PMRT). The document can be viewed online or downloaded here.

Letter for parents engaging them in review (PMRT) – deaths during or after birth

This template is designed to engage parents whose baby died during or after birth, in conjunction with the use of the Perinatal Mortality Review Tool (PMRT). The document can be viewed online or downloaded here.