The Perinatal Mortality Review Tool (PMRT) collaboration, co-led by Oxford Population Health’s National Perinatal Epidemiology Unit, has today published their seventh set of findings and recommendations for hospitals and care providers who carry out reviews of the care received by babies who died in pregnancy from 22 weeks’ gestation onwards or died within 28 days of being born (perinatal deaths).
This report presents the findings from 4,166 reviews completed from January 2024 to December 2024.
Key findings:
- During 2024, a review of care was started for 99% of all babies who died in the perinatal period and 95% of babies who died in the neonatal period (within 28 days of being born). Overall, only 84% of reviews were completed;
- In 19 out of 20 reviews, PMRT panels identified at least one issue with care. In seven out of 20 reviews, at least one issue was identified and judged by the review teams to have been relevant to the outcome. This represents an increase from six out of 20 reviews in 2023;
- Clinicians reported that 99% of parents in the UK overall were informed that a review of their care would take place. Of the parents who were told that a review would take place, clinicians report that 98% of parents were asked about their care as part of the review process but only 56% of reviews included comments from parents that could be analysed for the report;
- In a random sample of 200 parent comments collected during the review process, 28% were questions about specific aspects of their care. Concerns about management plans and the care received were raised in 22% of the comments analysed;
- Positive comments about the treatment and support received were present in 18% of comments contributed by parents. Overall, there were 12% of reports with concerns from parents about how they were approached by staff and how care was given.
- Having an external panel member present for the review, who is able to provide a ‘fresh eyes’ independent robust challenge has increased from 51% of reviews in 2023 to 53% in 2024;
- Having a neonatologist or paediatrician present for reviews of neonatal deaths increased from 84% in 2023 to 87% in 2024;
- The most common issue with care identified during the antenatal period was late booking or being un-booked for care, which was identified in 28% of reviews;
- The most common issue identified during labour and birth was maternal monitoring in labour, which was identified in 19% of reviews;
- The inadequate location and quality of bereavement suites affected one in 20 families, which showed a marginal improvement on 2023.
- The proportion of action plans that were described as ‘strong’ and ‘intermediate’ has remained steady at about 50%;
The report sets out six key recommendations for a range of stakeholders, including staff caring for bereaved parents, review teams, trusts and health boards, service commissioners and governments:
- Optimise the engagement of parents in reviews by ensuring all parents are approached, that staff are trained to support parents and to enable them to provide their perspectives and any questions they have using the PMRT engagement materials;
- Ensure that PMRT review teams are adequately resourced so that all appropriate staff are able to attend and contribute to PMRT review meetings;
- Ensure that PMRT review roles are incorporated into consultant job plans and all other relevant role descriptions. Senior leadership is essential and should be designated as part of job plans and role descriptions;
- Provide adequate resources and make the support arrangements necessary to ensure the participation of independent external clinicians at the multi-disciplinary PMRT review meeting;
- Use the findings from local PMRT summary reports and this national report, alongside MBRRACE-UK real-time monitoring tool data to prioritise resources for key care quality improvement activities identified as requiring action;
- Enhance the impact of review findings by generating ‘strong’ actions targeted at system level changes, developing and implementing service quality improvement activities based on review findings, and rigorously auditing their implementation and impact.
Emeritus Professor Jenny Kurinczuk, PMRT National Programme Lead, said ‘When a baby has died a high-quality review of care is essential to enable parents to understand why their baby died, what happened with their care and, whether with different care, the outcome for them and their baby may have been different. Critically, high-quality reviews need to be conducted to identify where service improvements are required to improve care for all mothers and babies, to prevent future deaths and to improve care when a death has occurred.
‘Audit and review are part of routine maternity and neonatal care; these are not optional extras. It is therefore reassuring to see that for the vast majority of baby deaths in 2024 a review using the PMRT was started (97%) and for 84% the review was completed and the final report generated. Although there is variation by country, this represents a major improvement since the launch of the PMRT in 2018.
‘It is also heartening to see an increase in the proportion of reviews where a senior independent clinician (an external member) was present for the multi-disciplinary review. Externals are able to provide independent, robust challenge in the discussions about the care provided and improve the quality of the review. We know from research that bereaved parents find it reassuring to have an external present. Otherwise, parents can perceive hospitals as “marking their own homework”.’
Since it was launched in 2018, all trusts and health boards across England, Wales, Scotland and Northern Ireland have adopted the PMRT and over 29,000 reviews have been started and/or completed using the tool. The PMRT supports local review teams to conduct objective, robust, and standardised local reviews of care when babies die. This is to provide answers for bereaved parents and their families as to whether the care that they and their baby received was appropriately safe and personalised, and whether different care may have changed the outcome.
The PMRT review findings also help to guide improvements in care of all mothers and babies, reduce safety-related adverse events, and prevent future baby deaths. For the majority of bereaved parents, the PMRT review process is likely to be the only review of their baby’s death that will take place.
The PMRT is funded in England by the Department of Health and Social Care (DHSC) and commissioned by the DHSC on behalf of NHS Wales, the Health and Social Care Division of the Scottish Government, and the Northern Ireland Department of Health.