In order to prevent deaths which are potentially avoidable, it is vital that the health service reviews the care mother and baby received when things go wrong.

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 stillbirths, the stillbirth might have been prevented if health professionals had followed national guidelines. An enquiry in 2017 found that 80% of babies who died as a result of something going wrong in labour might also have been prevented had babies received different care. Although professional groups recommend that hospitals review what happened when a baby dies unexpectedly, the confidential enquiries routinely find that only one in ten hospitals carry out a review and many of these are 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

Parents should be engaged in this process too. We are leading work to ensure that this happens in a sensitive and meaningful way, and are also involved in a number of initiatives across the UK to improve the ways lessons are learnt after the death of a baby.

Perinatal Mortality Review Tool (PMRT)

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. This is now available for free across England, Scotland and Wales and supports robust reviews at every Trust or Health Board.

 Sands is now directly involved in the development of the PMRT which is run by a collaboration led by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK). This 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/Department of Health led expert group which agreed what should be included in good-quality hospital reviews through a series of workshops in 2012 to 2015. It was as a result of this ground work that the Health Quality Improvement Partnership (HQIP) commissioned the PMRT in 2016 to support good-quality hospital reviews.

Sands' aim is to ensure that the voice of parents is at the heart of any review process, and that they are given the opportunity to ask questions and give their perspective of their care. It is also vital that the findings of any review are shared openly and honestly with parents.

For more information about the new national Perinatal Mortality Review Tool (PMRT) go to:

To see why it's important to offer parents the opportunity to share their views and questions as part of the review process download "Role of parents in reviews" presentation.

Engaging parents in review

Sands has been instrumental in supporting the PMRT to develop a series of tools for health professionals to help guide them in engaging parents in the review of their baby's death. This will include a flowchart for engagement, parent information leaflets, template letters for parents informing them of the process, and a guide to writing plain English summaries. They will be available very soon on this and the PMRT website.

In the meantime, the following letter templates have been designed to help healthcare professionals introduce parents to the Perinatal Mortality Review process, in conjunction with the use of the Perinatal Mortality Review Tool (PMRT). The letters were developed by the Sands/Department of Health Task and Finish Group to standardise perinatal mortality review and have been updated in 2018 by the National Bereavement Care Pathway Parent Advisory Group. 

Download 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.

Download 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.

Each Baby Counts 

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

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

For more information on Each Baby Counts, go to

Sands' role

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

We ran a survey of over 270 parents about involving parents in the review of their baby’s care for the 2016 progress report and which we presented at the report launch.